Provider Demographics
NPI:1306632344
Name:AJISAFE, MODUPE HARRIET (MD)
Entity type:Individual
Prefix:MISS
First Name:MODUPE
Middle Name:HARRIET
Last Name:AJISAFE
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 1:1855 LAKELAND DR APT 415
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-0005
Mailing Address - Country:US
Mailing Address - Phone:346-370-2417
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF FAMILY MEDICINE
Practice Address - Street 2:2500 N STATE ST
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST5940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine