Provider Demographics
NPI:1144577826
Name:AJAYEOBA, OLUMIDE O (MD)
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:O
Last Name:AJAYEOBA
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0001
Practice Address - Country:US
Practice Address - Phone:570-271-6439
Practice Address - Fax:570-271-6852
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01431208M00000X
PAMD467704207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01374327OtherRAILROAD MEDICARE
NC1144577826Medicaid
NC1144577826OtherTRICARE
NC1869MOtherBCBS
NC1144577826OtherTRICARE