Provider Demographics
NPI:1821133588
Name:ADEWALE, OLUSINA (MD)
Entity Type:Individual
Prefix:
First Name:OLUSINA
Middle Name:
Last Name:ADEWALE
Suffix:
Gender:M
Credentials:MD
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 22944
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-2944
Mailing Address - Country:US
Mailing Address - Phone:423-485-9008
Mailing Address - Fax:
Practice Address - Street 1:7693 RHEA COUNTY HWY
Practice Address - Street 2:#8
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-6082
Practice Address - Country:US
Practice Address - Phone:423-775-8117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD028688208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3810868Medicare PIN
G49120Medicare UPIN