Provider Demographics
NPI:1245320480
Name:GBADEBO, BOLANLE O (MD)
Entity type:Individual
Prefix:
First Name:BOLANLE
Middle Name:O
Last Name:GBADEBO
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 1:7400 MERTON MINTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:920-217-0539
Mailing Address - Fax:
Practice Address - Street 1:9939 STATE HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1900
Practice Address - Country:US
Practice Address - Phone:210-949-9702
Practice Address - Fax:210-443-0333
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46201207Q00000X
AL28814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34586000Medicaid
I19551Medicare UPIN
WI086672200Medicare ID - Type Unspecified