Provider Demographics
NPI:1215991989
Name:ADIATU, ISMAILA ODUOLA (MD)
Entity type:Individual
Prefix:DR
First Name:ISMAILA
Middle Name:ODUOLA
Last Name:ADIATU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1774 JASEN AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-2432
Mailing Address - Country:US
Mailing Address - Phone:516-285-8604
Mailing Address - Fax:516-285-8604
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-3408
Practice Address - Fax:718-747-3618
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH10640Medicare UPIN