Provider Demographics
NPI:1629038930
Name:ADETONA, ADETUTU BASIRAT (MD)
Entity Type:Individual
Prefix:DR
First Name:ADETUTU
Middle Name:BASIRAT
Last Name:ADETONA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-2501
Mailing Address - Country:US
Mailing Address - Phone:518-235-8034
Mailing Address - Fax:518-235-8036
Practice Address - Street 1:595 5TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-2501
Practice Address - Country:US
Practice Address - Phone:518-235-8034
Practice Address - Fax:518-235-8036
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205662-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01746818Medicaid
NYG47846Medicare UPIN