Provider Demographics
NPI:1306920756
Name:ADENIYI, JOHN A (MD, FACS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ADENIYI
Suffix:
Gender:M
Credentials:MD, FACS
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 890
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0890
Mailing Address - Country:US
Mailing Address - Phone:304-842-3993
Mailing Address - Fax:304-842-4083
Practice Address - Street 1:527 MEDICAL PARK DR STE 501
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-3993
Practice Address - Fax:304-842-4083
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV212932085R0204X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00093109OtherRR MC
WV001719007OtherBCBS
WV3810000654Medicaid
WVP00093109OtherRR MC
WV3810000654Medicaid