Provider Demographics
NPI:1336121946
Name:OGUNTOLA, ADEBOWALE OGUNSEYE (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEBOWALE
Middle Name:OGUNSEYE
Last Name:OGUNTOLA
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 1:663 LANIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2059
Mailing Address - Country:US
Mailing Address - Phone:678-450-0202
Mailing Address - Fax:678-450-0080
Practice Address - Street 1:663 LANIER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2059
Practice Address - Country:US
Practice Address - Phone:678-450-0202
Practice Address - Fax:678-450-0080
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212959207RN0300X
GA97988207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02076084Medicaid
NY000025670OtherEXCELLUS PROVIDER NUMBER
NY02076084Medicaid
NYH19544Medicare UPIN