Provider Demographics
NPI:1720116544
Name:ADEYEYE, SAMUEL OYEWOLE (RD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OYEWOLE
Last Name:ADEYEYE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1046
Mailing Address - Country:US
Mailing Address - Phone:914-526-0606
Mailing Address - Fax:
Practice Address - Street 1:148 WILSON AVENUE
Practice Address - Street 2:COMPREHENSIVE HEALTH CARE AND REHABILITATION SERVICES
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3149
Practice Address - Country:US
Practice Address - Phone:718-455-5500
Practice Address - Fax:718-455-8700
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005445133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
9244E1Medicare ID - Type Unspecified