Provider Demographics
NPI:1053654814
Name:ADEYEYE, GBENGA ADEYEMI (DO)
Entity type:Individual
Prefix:DR
First Name:GBENGA
Middle Name:ADEYEMI
Last Name:ADEYEYE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 RACHEL TER APT 18
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9360
Mailing Address - Country:US
Mailing Address - Phone:757-343-1829
Mailing Address - Fax:
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:757-619-2749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05998363A00000X
VA0110004213363A00000X
NY3309542085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10106951POtherOPTIMA HEALTH PLAN
VA1053654814Medicaid
VA493474OtherBCBSVA
VAP01192419OtherRAILROAD MEDICARE
VA10106951POtherSENTARA HEALTH PLAN
VA1053654814OtherTRICARE PRIME NETWORK
VA10112734POtherSENTARA HEALTH PLAN
VA10112734POtherOPTIMA HEALTH PLAN
VA178PYOtherBCBSNC
VA1053654814Medicaid