Provider Demographics
NPI:1043384654
Name:ODULAJA, KOLAWOLE ADEMUYIWA (MD)
Entity Type:Individual
Prefix:
First Name:KOLAWOLE
Middle Name:ADEMUYIWA
Last Name:ODULAJA
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 1:510 MED CT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3482
Mailing Address - Country:US
Mailing Address - Phone:210-455-0074
Mailing Address - Fax:210-455-0124
Practice Address - Street 1:510 MED CT
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3482
Practice Address - Country:US
Practice Address - Phone:210-455-0074
Practice Address - Fax:210-455-0124
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2694207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201404510Medicaid
8CJ963OtherBLUE CROSS BLUE SHIELD OF TEXAS
8CJ963OtherBLUE CROSS BLUE SHIELD OF TEXAS