Provider Demographics
NPI:1770033276
Name:MOGBONJUBOLA A ADEYEMO MD PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MOGBONJUBOLA A ADEYEMO MD PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-369-9853
Mailing Address - Street 1:361 N SAN JACINTO ST
Mailing Address - Street 2:SUITE A B C
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3118
Mailing Address - Country:US
Mailing Address - Phone:951-492-0728
Mailing Address - Fax:
Practice Address - Street 1:361 N SAN JACINTO ST
Practice Address - Street 2:SUITE A B C
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3118
Practice Address - Country:US
Practice Address - Phone:951-492-0728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty