Provider Demographics
NPI:1457711277
Name:ADEMIJU, AGBOADE
Entity Type:Individual
Prefix:
First Name:AGBOADE
Middle Name:
Last Name:ADEMIJU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 MACON ST
Mailing Address - Street 2:APT 4R
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-1673
Mailing Address - Country:US
Mailing Address - Phone:234-307-3192
Mailing Address - Fax:
Practice Address - Street 1:900 INTERVALE AVE,
Practice Address - Street 2:ARCHCARE, BRONX
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459
Practice Address - Country:US
Practice Address - Phone:718-732-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY595738163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse