Provider Demographics
NPI:1881776219
Name:ADETOLA, ADEGBENGA A (MD)
Entity type:Individual
Prefix:MR
First Name:ADEGBENGA
Middle Name:A
Last Name:ADETOLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3591 EAST IMPERIAL HIGHWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-631-2838
Mailing Address - Fax:310-632-4701
Practice Address - Street 1:3591 EAST IMPERIAL HIGHWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-631-2838
Practice Address - Fax:310-632-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-06-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA55507207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A555070Medicaid
H00163Medicare UPIN
CA00A555070Medicaid