Provider Demographics
NPI:1992192025
Name:ADESIDA, OLUWAYEMISI A (MD)
Entity Type:Individual
Prefix:
First Name:OLUWAYEMISI
Middle Name:A
Last Name:ADESIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YEMISI
Other - Middle Name:
Other - Last Name:ADESIDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:MED/PEDS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2528
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:MED/PEDS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312549208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics