Provider Demographics
NPI:1235111469
Name:SOBOWALE, ADEYEMI O (MD)
Entity Type:Individual
Prefix:
First Name:ADEYEMI
Middle Name:O
Last Name:SOBOWALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SIXTH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-438-7430
Mailing Address - Fax:330-580-5542
Practice Address - Street 1:2600 SIXTH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-438-7430
Practice Address - Fax:330-580-5542
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350743202080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0759746OtherMEDICAID GROUP NUMBER
1275635351OtherGROUP NPI
OH2131197Medicaid