Provider Demographics
NPI:1487638854
Name:ADETUNJI, ADEMUYIWA ADEKOLA (DPM)
Entity Type:Individual
Prefix:DR
First Name:ADEMUYIWA
Middle Name:ADEKOLA
Last Name:ADETUNJI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 265
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-0265
Mailing Address - Country:US
Mailing Address - Phone:301-386-5453
Mailing Address - Fax:301-386-5396
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:STE 151
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:301-386-5453
Practice Address - Fax:301-386-5396
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01264213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD319906101Medicaid
MD319906101Medicaid
MD319906101Medicaid
MD210NMedicare ID - Type UnspecifiedBALTIMORE OFFICES