Provider Demographics
NPI:1841301884
Name:ASEBIOMO, BANKOLE SIMBO (MD)
Entity type:Individual
Prefix:
First Name:BANKOLE
Middle Name:SIMBO
Last Name:ASEBIOMO
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 1:3041 SKY WATCH WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9378
Mailing Address - Country:US
Mailing Address - Phone:916-477-4944
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:229-391-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045706207R00000X, 207RI0200X
VA0101242047208M00000X
CAC163303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000849329DMedicaid
VA1841301884Medicaid
VAP00417087OtherMEDICARE RAILROAD
VA014428S90Medicare PIN
GA11SCDMQMedicare ID - Type UnspecifiedMEDICARE
VAP00417087OtherMEDICARE RAILROAD
GA000849329DMedicaid