Provider Demographics
NPI:1104196641
Name:ADEKOLA, HENRY OLUGBENGA (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:OLUGBENGA
Last Name:ADEKOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HENRY
Other - Middle Name:OLUGBENGA
Other - Last Name:ADEKOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:400 N 9TH ST FL 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5310
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6388
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-143019207VM0101X, 207V00000X
IN0108320A207VM0101X
NY207V00000X207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid