Provider Demographics
NPI:1073510103
Name:OLAYIWOLA, JACQUELINE NWANDO (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NWANDO
Last Name:OLAYIWOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:NWANDO
Other - Last Name:ONYEJEKWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-688-6490
Mailing Address - Fax:614-688-6491
Practice Address - Street 1:543 TAYLOR AVE FL 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1278
Practice Address - Country:US
Practice Address - Phone:614-688-6490
Practice Address - Fax:614-688-6491
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35137342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid
CT080001750Medicare ID - Type Unspecified
CT004236346Medicaid