Provider Demographics
NPI:1790702132
Name:ADEWALE, BENJAMIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:A
Last Name:ADEWALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:
Other - Last Name:ADEWALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PC
Mailing Address - Street 1:PO BOX 8057
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-8057
Mailing Address - Country:US
Mailing Address - Phone:703-569-8028
Mailing Address - Fax:703-569-8085
Practice Address - Street 1:7011 CALAMO ST
Practice Address - Street 2:#105
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150
Practice Address - Country:US
Practice Address - Phone:703-569-8028
Practice Address - Fax:703-569-8085
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD220042084N0400X
MDD508742084N0400X
VA01010541652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2033020-00Medicaid
DC4401280Medicaid
VA7107820Medicaid
DC877428Medicare ID - Type Unspecified