Basic Information
Provider Information
NPI: 1003005661
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OKETOKUN
FirstName: ADEFOLAJU
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: OLUFUWA
OtherFirstName: ADEFOLAJU
OtherMiddleName:  
OtherNamePrefix: DR.
OtherNameSuffix:  
OtherCredential: MD
OtherLastNameType: 1
Mailing Information
Address1: 1818 NEW YORK AVE NE
Address2: SUITE 110
City: WASHINGTON
State: DC
PostalCode: 200021848
CountryCode: US
TelephoneNumber: 2026365136
FaxNumber:  
Practice Location
Address1: 1818 NEW YORK AVE NE
Address2: SUITE 110
City: WASHINGTON
State: DC
PostalCode: 200021848
CountryCode: US
TelephoneNumber: 2026365136
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/19/2007
LastUpdateDate: 08/16/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000XC1-0008405DEN Allopathic & Osteopathic PhysiciansGeneral Practice 
261Q00000XMD 038372DCY Ambulatory Health Care FacilitiesClinic/Center 
261Q00000XMD430487PAN Ambulatory Health Care FacilitiesClinic/Center 
261QU0200XMD 038372DCN Ambulatory Health Care FacilitiesClinic/CenterUrgent Care
332B00000XMD038372DCN SuppliersDurable Medical Equipment & Medical Supplies 

ID Information
IDTypeStateIssuerDescription
04059750005DC MEDICAID


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