Provider Demographics
NPI:1649421934
Name:ADEYEKUN, OMOBOLANLE OMOLAYO (MD)
Entity Type:Individual
Prefix:DR
First Name:OMOBOLANLE
Middle Name:OMOLAYO
Last Name:ADEYEKUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:OMOBOLANLE
Other - Middle Name:OMOLAYO
Other - Last Name:ONIBONOJE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:39 EUCLID AVE
Mailing Address - Street 2:#2A
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-4565
Mailing Address - Country:US
Mailing Address - Phone:516-941-6230
Mailing Address - Fax:
Practice Address - Street 1:2620 N. WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-727-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-04
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010021661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1649421934Medicaid
MO148160019Medicare PIN