Provider Demographics
NPI:1932174588
Name:HAASTRUP, ADETOLA TOLULOLA (MD)
Entity Type:Individual
Prefix:MRS
First Name:ADETOLA
Middle Name:TOLULOLA
Last Name:HAASTRUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ADETOLA
Other - Middle Name:TOLULOLA
Other - Last Name:AJAYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-2300
Practice Address - Fax:701-780-1942
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086777207R00000X, 207RN0300X
ND11376207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34689000Medicaid
MI4779526Medicaid
MI0B26002077Medicare ID - Type UnspecifiedMI MEDICARE
MI4779526Medicaid