Provider Demographics
NPI:1275726515
Name:AJEGBA, FOLASHADE O (MD)
Entity Type:Individual
Prefix:DR
First Name:FOLASHADE
Middle Name:O
Last Name:AJEGBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FOLASHADE
Other - Middle Name:OMODELE
Other - Last Name:AJAKAIYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:990 STEWART AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4822
Mailing Address - Country:US
Mailing Address - Phone:516-222-2022
Mailing Address - Fax:
Practice Address - Street 1:990 STEWART AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4822
Practice Address - Country:US
Practice Address - Phone:516-222-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274344-12085R0202X
CT486932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3101093Medicaid
OHP00891133OtherRAILROAD MEDICARE
OHAJ4311891Medicare PIN
OH3101093Medicaid