Provider Demographics
NPI:1710930011
Name:ADISA, FATAI BOLAJI (PT)
Entity Type:Individual
Prefix:
First Name:FATAI
Middle Name:BOLAJI
Last Name:ADISA
Suffix:
Gender:M
Credentials:PT
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 10644
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46411-0644
Mailing Address - Country:US
Mailing Address - Phone:219-525-4176
Mailing Address - Fax:219-750-9451
Practice Address - Street 1:8691 CONNECTICUT ST
Practice Address - Street 2:STE C
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5541
Practice Address - Country:US
Practice Address - Phone:219-525-4176
Practice Address - Fax:219-472-0841
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005905A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201269820AMedicaid