Provider Demographics
NPI:1497017867
Name:ADENIRAN, JANELLE MARIE FASSBENDER (MD)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:MARIE FASSBENDER
Last Name:ADENIRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANELLE
Other - Middle Name:MARIE
Other - Last Name:FASSBENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1935 BLUEGRASS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1181
Mailing Address - Country:US
Mailing Address - Phone:502-364-0033
Mailing Address - Fax:
Practice Address - Street 1:1935 BLUEGRASS AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-364-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01080878A207W00000X, 207WX0107X
KY49029207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100257450Medicaid
IN201397580Medicaid
IN201397580Medicaid