Provider Demographics
NPI:1164413472
Name:AJAYI, ANDREA BAOWANG (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:BAOWANG
Last Name:AJAYI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2526
Mailing Address - Country:US
Mailing Address - Phone:209-747-5918
Mailing Address - Fax:209-931-1285
Practice Address - Street 1:1800 HARRISON ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3466
Practice Address - Country:US
Practice Address - Phone:510-625-6262
Practice Address - Fax:510-625-6226
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72668207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A726880Medicaid
CA00A726684Medicare PIN
CA00A726880Medicaid
CA00A726883Medicare PIN