Provider Demographics
NPI:1770560435
Name:OYELESE, ADETOKUNBO ADEGBOYEGA (MD, PHD)
Entity type:Individual
Prefix:
First Name:ADETOKUNBO
Middle Name:ADEGBOYEGA
Last Name:OYELESE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CLAVERICK ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4144
Mailing Address - Country:US
Mailing Address - Phone:401-490-4130
Mailing Address - Fax:401-455-1292
Practice Address - Street 1:55 CLAVERICK ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4144
Practice Address - Country:US
Practice Address - Phone:401-490-4130
Practice Address - Fax:401-455-1292
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11630207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
I25467Medicare UPIN