Provider Demographics
NPI:1114570561
Name:RAJI, ADEMOLA I
Entity Type:Individual
Prefix:
First Name:ADEMOLA
Middle Name:I
Last Name:RAJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 9TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2634
Mailing Address - Country:US
Mailing Address - Phone:415-425-6483
Mailing Address - Fax:
Practice Address - Street 1:1924 9TH AVE APT 202
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-2634
Practice Address - Country:US
Practice Address - Phone:415-425-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF8138136172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver