Provider Demographics
NPI:1336474287
Name:OLUSEGUN M ADEONIGBAGBE MDPC
Entity Type:Organization
Organization Name:OLUSEGUN M ADEONIGBAGBE MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUSEGUN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ADEONIGBAGBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-217-7744
Mailing Address - Street 1:19203 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2529
Mailing Address - Country:US
Mailing Address - Phone:718-217-7744
Mailing Address - Fax:718-217-7233
Practice Address - Street 1:19203 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2529
Practice Address - Country:US
Practice Address - Phone:718-217-7744
Practice Address - Fax:718-217-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201260261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy