Provider Demographics
NPI:1760829873
Name:GBADAMOSI, BOLANLE MARIAM (MD)
Entity type:Individual
Prefix:DR
First Name:BOLANLE
Middle Name:MARIAM
Last Name:GBADAMOSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BOLANLE
Other - Middle Name:MARIAM
Other - Last Name:SHODEINDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2711 X RAY DR STE 3701
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7491
Practice Address - Country:US
Practice Address - Phone:980-834-9600
Practice Address - Fax:980-834-9605
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266137207RH0003X
NC2019-01346207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology