Provider Demographics
NPI:1174648489
Name:ADEOSUN, OLANREWAJU (MD)
Entity Type:Individual
Prefix:
First Name:OLANREWAJU
Middle Name:
Last Name:ADEOSUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1711 RALPH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236
Mailing Address - Country:US
Mailing Address - Phone:347-276-6234
Mailing Address - Fax:718-649-6357
Practice Address - Street 1:1711 RALPH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3319
Practice Address - Country:US
Practice Address - Phone:347-276-6234
Practice Address - Fax:718-649-6357
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01729900Medicaid
NY2506487OtherGHI
NYOH351OtherBLUE CROSS
NYOH351OtherBLUE CROSS
NY15N402Medicare ID - Type UnspecifiedMEDICARE PROVIDER