Provider Demographics
NPI:1902884364
Name:TAIWO, ADEBUKOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEBUKOLA
Middle Name:
Last Name:TAIWO
Suffix:
Gender:M
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:PO BOX 40908
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-0908
Mailing Address - Country:US
Mailing Address - Phone:910-609-6448
Mailing Address - Fax:910-609-7040
Practice Address - Street 1:101 ROBESON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5552
Practice Address - Country:US
Practice Address - Phone:910-609-1630
Practice Address - Fax:910-609-1636
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0090-00454207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902372Medicaid
NC2048402Medicare PIN
NCI37822Medicare UPIN