Provider Demographics
NPI:1346731635
Name:ADEWALE, SAMSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMSON
Middle Name:
Last Name:ADEWALE
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 1:200 TOWN MADISON BLVD APT 3211
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-6692
Mailing Address - Country:US
Mailing Address - Phone:404-644-3747
Mailing Address - Fax:
Practice Address - Street 1:1170 CLEVELAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-7900
Practice Address - Fax:770-999-2860
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.43245207P00000X, 207Q00000X
OK390200000X
GA92679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program