Provider Demographics
NPI:1669544169
Name:ADEGBOLA, ABIDEMI ADETOYESE (MD)
Entity type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:ADETOYESE
Last Name:ADEGBOLA
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 1:834 CHESTNUT ST
Mailing Address - Street 2:PH113
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5127
Mailing Address - Country:US
Mailing Address - Phone:314-348-4546
Mailing Address - Fax:
Practice Address - Street 1:3905 FORD RD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2824
Practice Address - Country:US
Practice Address - Phone:215-220-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227766207SG0201X
NH130622084P0800X, 2084P0804X
PAMD4465832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry