Provider Demographics
NPI:1275930422
Name:ADEYEYE, OLUBUKOLA T (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUBUKOLA
Middle Name:T
Last Name:ADEYEYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:OLUBUKOLA
Other - Middle Name:T
Other - Last Name:AJISAFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1801 BLACK RIVER BLVD N
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2427
Mailing Address - Country:US
Mailing Address - Phone:315-337-3770
Mailing Address - Fax:315-337-5380
Practice Address - Street 1:1801 BLACK RIVER BLVD N
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2427
Practice Address - Country:US
Practice Address - Phone:315-337-3770
Practice Address - Fax:315-337-5380
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281482208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY281482OtherLICENSE