Provider Demographics
NPI:1720088016
Name:ADEDIPE, OLUGBENGA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUGBENGA
Middle Name:
Last Name:ADEDIPE
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 1:510 HIGHWAY 322
Mailing Address - Street 2:P O BOX 1216
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4717
Mailing Address - Country:US
Mailing Address - Phone:662-624-4292
Mailing Address - Fax:662-624-4354
Practice Address - Street 1:1820 PEABODY ST
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676-9441
Practice Address - Country:US
Practice Address - Phone:662-363-3656
Practice Address - Fax:662-363-3789
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20415208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02635095Medicaid
MS02635095Medicaid