Provider Demographics
NPI:1629023064
Name:ADELEYE, OLUSEGUN ADEDAMOLA (MD)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:ADEDAMOLA
Last Name:ADELEYE
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 1:405 BIENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5748
Mailing Address - Country:US
Mailing Address - Phone:318-356-7211
Mailing Address - Fax:
Practice Address - Street 1:405 BIENVILLE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5748
Practice Address - Country:US
Practice Address - Phone:318-356-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1582018Medicaid
LA4K288DD68Medicare PIN