Provider Demographics
NPI:1306820121
Name:ADEYANJU, MOSES O (MD)
Entity type:Individual
Prefix:DR
First Name:MOSES
Middle Name:O
Last Name:ADEYANJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-351-4957
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077955207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077955-2Medicaid
ILK20008Medicare ID - Type Unspecified
G84081Medicare UPIN
IL214881Medicare Oscar/Certification