Provider Demographics
NPI:1003898230
Name:AJAYI, OLUADE A (MBBS)
Entity Type:Individual
Prefix:
First Name:OLUADE
Middle Name:A
Last Name:AJAYI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE NO
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5731
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH AVE NO
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN456432080A0000X, 2080N0001X
IL0360700022080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMPOtherONE HEALTH PLAN
COMPOtherCHAMPUS
09 25 2003OtherMMSI
458988200OtherMEDICAL ASSISTANCE MA
COMOtherGREAT WEST
1034801OtherPREFERRED ONE
274R4AJOtherBLUE CROSS BLUE SHIELD
1908369OtherARAZ GROUP
1908369OtherAMERICAS PPO
MN458988200Medicaid
NEOtherRR MEDICARE
4700129OtherMEDICA HEALTH PLANS
171809OtherU CARE
2115953OtherFIRST HEALTH PLAN
HP39081OtherHEALTH PARTNERS
HP39081OtherHEALTH PARTNERS
370002755Medicare PIN
171809OtherU CARE
NEOtherRR MEDICARE