Provider Demographics
NPI:1467533661
Name:ADEWALE, ADEYINKA A (OD)
Entity Type:Individual
Prefix:
First Name:ADEYINKA
Middle Name:A
Last Name:ADEWALE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 GODFREY RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2558
Mailing Address - Country:US
Mailing Address - Phone:618-466-8787
Mailing Address - Fax:618-466-4703
Practice Address - Street 1:3300 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2558
Practice Address - Country:US
Practice Address - Phone:618-466-8787
Practice Address - Fax:618-466-4703
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1467533661Medicaid
ILU79958Medicare UPIN
IL1467533661Medicaid
IL0728570001Medicare NSC