Provider Demographics
NPI:1619186004
Name:ADESO, MUKONG (MD)
Entity Type:Individual
Prefix:
First Name:MUKONG
Middle Name:
Last Name:ADESO
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:434-972-4266
Practice Address - Street 1:UVA HOSPITAL
Practice Address - Street 2:LEE STREET 1ST FLOOR
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-924-9954
Practice Address - Fax:434-982-6726
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116015832390200000X
VA0101244064208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619186004Medicaid
P00768138Medicare PIN
VA00Y133R02Medicare PIN