Provider Demographics
NPI:1306006218
Name:AYENI, TINA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:A
Last Name:AYENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ABISOLA
Other - Middle Name:
Other - Last Name:AYENI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8111 S EMERSON AVE STE 204
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-2555
Practice Address - Fax:317-528-2566
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC128304207V00000X
MN52152207VX0201X
TXP4545207VX0201X
MN104397207VX0201X
IN01076188A207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308690201 (MDACC)Medicaid
MN980000058Medicare PIN
TX308690201 (MDACC)Medicaid