Provider Demographics
NPI:1265521702
Name:ADEKANMBI, ADEBOLA (PT)
Entity type:Individual
Prefix:MR
First Name:ADEBOLA
Middle Name:
Last Name:ADEKANMBI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39717
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9717
Mailing Address - Country:US
Mailing Address - Phone:623-939-3112
Mailing Address - Fax:623-939-3106
Practice Address - Street 1:8433 N BLACK CANYON HWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4873
Practice Address - Country:US
Practice Address - Phone:623-939-3112
Practice Address - Fax:623-939-3106
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39512251G0304X, 2251N0400X, 2251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ495160Medicaid