Provider Demographics
NPI:1679007736
Name:ADETOBA, OLADUNNI MODUPEOLA (MD)
Entity type:Individual
Prefix:
First Name:OLADUNNI
Middle Name:MODUPEOLA
Last Name:ADETOBA
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 1:1001 GAUSE BLVD # 4
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2939
Mailing Address - Country:US
Mailing Address - Phone:985-280-8743
Mailing Address - Fax:985-280-8554
Practice Address - Street 1:1001 GAUSE BLVD # 4
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:985-280-8743
Practice Address - Fax:985-280-8554
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA323946207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program