Provider Demographics
NPI:1952614851
Name:ADELOLA, OLUBUKOLA ABIGAIL (MD)
Entity type:Individual
Prefix:DR
First Name:OLUBUKOLA
Middle Name:ABIGAIL
Last Name:ADELOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 S KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2607
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-394-9575
Practice Address - Street 1:4463 STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-8727
Practice Address - Country:US
Practice Address - Phone:419-628-3821
Practice Address - Fax:419-628-9501
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321554207Q00000X
OH35.099923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH173472OtherMEDICARE PTAN
OH0079745Medicaid
NY321554OtherREGISTRATION