Provider Demographics
NPI:1790303782
Name:EDIALE, TEMI-ETE IRENE (MD)
Entity Type:Individual
Prefix:MRS
First Name:TEMI-ETE
Middle Name:IRENE
Last Name:EDIALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:TEMI-ETE
Other - Middle Name:IRENE
Other - Last Name:AFEJUKU-MUGURUSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:79-01 BROADWAY ELMHURST
Mailing Address - Street 2:C7-10
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-334-5028
Mailing Address - Fax:718-334-5292
Practice Address - Street 1:79-01 BROADWAY ELMHURST
Practice Address - Street 2:C7-10
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-334-5028
Practice Address - Fax:718-334-5292
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program