Provider Demographics
NPI:1013178763
Name:ADELADAN, AJIBADE (MD)
Entity Type:Individual
Prefix:
First Name:AJIBADE
Middle Name:
Last Name:ADELADAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-453-1008
Practice Address - Fax:559-453-2805
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1722742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00722957OtherRAILROAD MEDICARE
NE47066229013Medicaid
SD7729390Medicaid
NEP00681748OtherRAILROAD MEDICARE
NE10025598700Medicaid
CO50737821Medicaid
NE098368026Medicare PIN
NE47066229013Medicaid
CO279112YQKBMedicare PIN