Provider Demographics
NPI:1982749008
Name:GBENRO, SAMUEL AKINTOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:AKINTOLA
Last Name:GBENRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:9800 VALPARAISO DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4040
Practice Address - Country:US
Practice Address - Phone:219-934-9800
Practice Address - Fax:219-924-8831
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063139A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200870790Medicaid
IN247680BMedicare PIN
IN200870790Medicaid