1073570081 NPI number — DR. OLUSEGUN M ADEONIGBAGBE M.D.

Table of content: DR. OLUSEGUN M ADEONIGBAGBE M.D. (NPI 1073570081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073570081 NPI number — DR. OLUSEGUN M ADEONIGBAGBE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADEONIGBAGBE
Provider First Name:
OLUSEGUN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073570081
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 NORFOLK DRIVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMONT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-217-7744
Provider Business Mailing Address Fax Number:
718-217-7233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19203 JAMAICA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11423-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-217-7744
Provider Business Practice Location Address Fax Number:
718-217-7233
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  201260 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2588825 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00010034 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: QN0067201 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3V1542 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01624886 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3C2885 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111948722AD03 . This is a "CAREPLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2506098 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000333540101 . This is a "HEALTHPLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P1300262 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03590 . This is a "GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 201260 . This is a "HIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201260-A16 . This is a "HEALTH FIRST" identifier . This identifiers is of the category "OTHER".




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