Provider Demographics
NPI:1063904639
Name:ADEGBEMI, AINA ADEDOYIN
Entity type:Individual
Prefix:
First Name:AINA
Middle Name:ADEDOYIN
Last Name:ADEGBEMI
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 1:3118 W DEVON AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1458
Mailing Address - Country:US
Mailing Address - Phone:773-407-9065
Mailing Address - Fax:
Practice Address - Street 1:3118 W DEVON AVE APT 1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1458
Practice Address - Country:US
Practice Address - Phone:773-407-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherNON
00000000001OtherNON
ILT46000175712OtherSTATE IDENTIFICATION NUMBER