Provider Demographics
NPI:1346265808
Name:ADESIDA, OLUREMI C (MD)
Entity Type:Individual
Prefix:
First Name:OLUREMI
Middle Name:C
Last Name:ADESIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:11115 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-373-9965
Practice Address - Fax:260-458-5664
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01068108A208000000X, 2080N0001X
IL036-116960208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000655415OtherANTHEM
IN200979870Medicaid
NJ8466700Medicaid
PA001289011Medicaid
PA039172Medicare PIN
IN000000655415OtherANTHEM