Provider Demographics
NPI:1811329071
Name:ADEWETAN, ADETOKUNBO TOLULOPE
Entity type:Individual
Prefix:MR
First Name:ADETOKUNBO
Middle Name:TOLULOPE
Last Name:ADEWETAN
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 1:1637 SAINT MARKS AVE APT 4R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-4839
Mailing Address - Country:US
Mailing Address - Phone:917-651-8893
Mailing Address - Fax:
Practice Address - Street 1:2 ROOSEVELT AVE STE 300
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3064
Practice Address - Country:US
Practice Address - Phone:516-496-4460
Practice Address - Fax:516-921-4432
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYSA68500NMedicaid