Provider Demographics
NPI:1073640496
Name:AZUBUIKE, ADISA A A (PHD)
Entity Type:Individual
Prefix:
First Name:ADISA
Middle Name:A A
Last Name:AZUBUIKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6485
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-6485
Mailing Address - Country:US
Mailing Address - Phone:518-857-5691
Mailing Address - Fax:
Practice Address - Street 1:925 BROADWAY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207
Practice Address - Country:US
Practice Address - Phone:518-857-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0127271103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01678055Medicaid
NY01678055Medicaid