Provider Demographics
NPI:1104011766
Name:BANKOLE, ADEGBENGA A (MD)
Entity type:Individual
Prefix:DR
First Name:ADEGBENGA
Middle Name:A
Last Name:BANKOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 RIVERS CIRCLE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-983-8229
Practice Address - Street 1:3 RIVERS CIRCLE
Practice Address - Street 2:SUITE 302
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-983-8229
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010245177207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014657Medicaid
VA540506332004OtherTRICARE