Provider Demographics
NPI:1548791940
Name:ADEKANMBI, ASHTON ADEKUNLE (MD)
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:ADEKUNLE
Last Name:ADEKANMBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122108 DEPT 2108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-7732
Mailing Address - Country:US
Mailing Address - Phone:337-480-8066
Mailing Address - Fax:337-480-8161
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4647
Practice Address - Country:US
Practice Address - Phone:337-480-8066
Practice Address - Fax:337-480-8161
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA323422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2442325Medicaid
LAMD.323422OtherSTATE LICENSE