Provider Demographics
NPI:1235518507
Name:AJISEBUTU, ADEKUNLE OLADEGA (MD)
Entity Type:Individual
Prefix:MR
First Name:ADEKUNLE
Middle Name:OLADEGA
Last Name:AJISEBUTU
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-358-9600
Mailing Address - Fax:515-358-9650
Practice Address - Street 1:1350 DES MOINES ST STE 100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5507
Practice Address - Country:US
Practice Address - Phone:515-358-9600
Practice Address - Fax:515-358-9650
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2022-05-25
Deactivation Date:2016-01-13
Deactivation Code:
Reactivation Date:2016-03-07
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAMD-47364207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program