Provider Demographics
NPI:1225131287
Name:ADOMAKO, PETRONELLA AGNES (MD)
Entity Type:Individual
Prefix:MS
First Name:PETRONELLA
Middle Name:AGNES
Last Name:ADOMAKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:757 45TH AVENUE
Mailing Address - Street 2:STE. 201
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-934-2461
Mailing Address - Fax:219-934-2478
Practice Address - Street 1:1400 S. LAKE PARK AVENUE
Practice Address - Street 2:STE. 305
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342
Practice Address - Country:US
Practice Address - Phone:219-945-1523
Practice Address - Fax:219-945-1284
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01059890A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200520520Medicaid
IN200520520Medicaid
IN499500 JJJJMedicare PIN