Provider Demographics
NPI:1922061977
Name:ADEGBILE, GIDEON S (MD)
Entity Type:Individual
Prefix:
First Name:GIDEON
Middle Name:S
Last Name:ADEGBILE
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 1:3033 KETTERING BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1962
Mailing Address - Country:US
Mailing Address - Phone:937-293-2133
Mailing Address - Fax:937-293-2161
Practice Address - Street 1:3033 KETTERING BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1962
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:937-293-2161
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-4541-A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214280Medicaid
OH4016910OtherAETNA PROVIDER NUMBER
OH000000189058OtherANTHEM PROVIDER NUMBER
P00122680Medicare PIN
OH0380176Medicare PIN
OH0214280Medicaid