Provider Demographics
NPI:1356372148
Name:ADETUNJI, BOSEDE O
Entity type:Individual
Prefix:
First Name:BOSEDE
Middle Name:O
Last Name:ADETUNJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15738 BOONRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77053-3732
Mailing Address - Country:US
Mailing Address - Phone:614-596-4626
Mailing Address - Fax:
Practice Address - Street 1:15738 BOONRIDGE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77053
Practice Address - Country:US
Practice Address - Phone:614-596-4626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112143164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2422257Medicaid