1568562478 NPI number — DR. AKINTUNDE ADEGITE OPTOMETRIST

Table of content: DR. AKINTUNDE ADEGITE OPTOMETRIST (NPI 1568562478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568562478 NPI number — DR. AKINTUNDE ADEGITE OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADEGITE
Provider First Name:
AKINTUNDE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OPTOMETRIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ADEGITE
Provider Other First Name:
LAWRENCE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OPTOMETRIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568562478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 S LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-5620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-326-0552
Provider Business Mailing Address Fax Number:
505-326-3308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 SOUTH LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-326-0552
Provider Business Practice Location Address Fax Number:
505-326-3308
Provider Enumeration Date:
09/22/2006

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: 152W00000X , with the licence number:  NM2399 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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