Provider Demographics
NPI:1477716348
Name:ADEOYE, OLUSANJO OLAOLUWA (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:OLUSANJO
Middle Name:OLAOLUWA
Last Name:ADEOYE
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Gender:M
Credentials:MD, MBA
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-8860
Practice Address - Fax:616-267-8442
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2017-02-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301104001207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477716348Medicaid
MI1477716348Medicaid