Provider Demographics
NPI:1457425613
Name:BALOGUN, ADEWALE MARK (RN)
Entity Type:Individual
Prefix:MR
First Name:ADEWALE
Middle Name:MARK
Last Name:BALOGUN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5485
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-0341
Mailing Address - Country:US
Mailing Address - Phone:631-897-8498
Mailing Address - Fax:631-666-1601
Practice Address - Street 1:49 GRASSLANDS CIR
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-1856
Practice Address - Country:US
Practice Address - Phone:631-897-8498
Practice Address - Fax:631-666-1601
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2583711164W00000X
NY642609-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02151077Medicaid