Provider Demographics
NPI:1962795658
Name:JEGEDE, KOLAWOLE (MD)
Entity type:Individual
Prefix:DR
First Name:KOLAWOLE
Middle Name:
Last Name:JEGEDE
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 1:6740 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-5350
Mailing Address - Country:US
Mailing Address - Phone:929-455-2000
Mailing Address - Fax:929-455-2020
Practice Address - Street 1:6740 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-5350
Practice Address - Country:US
Practice Address - Phone:929-455-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290224207XS0117X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program