Provider Demographics
NPI:1164677845
Name:BAMGBELU, OLUKAYODE ADEOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUKAYODE
Middle Name:ADEOLA
Last Name:BAMGBELU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLUKAYODE
Other - Middle Name:ADEOLA
Other - Last Name:BAMGBELU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:382 SUMMERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6926
Mailing Address - Country:US
Mailing Address - Phone:303-847-2970
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-4644
Practice Address - Fax:601-200-4645
Is Sole Proprietor?:No
Enumeration Date:2008-11-23
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45284207R00000X
KY42781207R00000X
TXQ1793207R00000X
FLME145551207R00000X
MS20917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1B9305OtherMEDICARE
MS05430527Medicaid