Provider Demographics
NPI:1114313590
Name:ADEDIPE, ADEFUNKE (MD)
Entity Type:Individual
Prefix:
First Name:ADEFUNKE
Middle Name:
Last Name:ADEDIPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 N LEAVITT RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1131
Mailing Address - Country:US
Mailing Address - Phone:440-988-1009
Mailing Address - Fax:
Practice Address - Street 1:3600 KOLBE RD STE 227
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053
Practice Address - Country:US
Practice Address - Phone:440-960-3304
Practice Address - Fax:440-960-4733
Is Sole Proprietor?:No
Enumeration Date:2015-04-12
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.133536207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0301107Medicaid