Provider Demographics
NPI:1285819821
Name:ADEWUNMI, ADESHOLA KAZEEM (MD)
Entity Type:Individual
Prefix:DR
First Name:ADESHOLA
Middle Name:KAZEEM
Last Name:ADEWUNMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 CHURCH ST NE
Mailing Address - Street 2:BOX 111
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1101
Mailing Address - Country:US
Mailing Address - Phone:770-793-7750
Mailing Address - Fax:770-793-7755
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:BOX 111
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-793-7750
Practice Address - Fax:770-793-7755
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064735207R00000X, 208M00000X
LA303015208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA363346743BMedicaid
GA363346743AMedicaid