Provider Demographics
NPI:1235421769
Name:AJAKAIYE, WALLACE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:A
Last Name:AJAKAIYE
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 1:1014 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-1978
Mailing Address - Country:US
Mailing Address - Phone:229-776-2965
Mailing Address - Fax:
Practice Address - Street 1:1014 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-1978
Practice Address - Country:US
Practice Address - Phone:229-776-2965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72271207Q00000X
GA5215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine