Provider Demographics
NPI:1285053223
Name:EGUNSOLA, ADEKEMI
Entity type:Individual
Prefix:
First Name:ADEKEMI
Middle Name:
Last Name:EGUNSOLA
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 1:900 NORTHERN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5302
Mailing Address - Country:US
Mailing Address - Phone:516-730-2100
Mailing Address - Fax:
Practice Address - Street 1:9525 QUEENS BLVD FL 5
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4510
Practice Address - Country:US
Practice Address - Phone:718-575-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298797208C00000X
GA98613208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery