Provider Demographics
NPI:1477049484
Name:ADESANYA, ADEBAMBO
Entity Type:Individual
Prefix:MR
First Name:ADEBAMBO
Middle Name:
Last Name:ADESANYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 TURTLE DOVE LN
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3082
Mailing Address - Country:US
Mailing Address - Phone:843-771-6505
Mailing Address - Fax:
Practice Address - Street 1:1008 TURTLE DOVE LN
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456
Practice Address - Country:US
Practice Address - Phone:843-771-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver