Provider Demographics
NPI:1366003477
Name:AJAYI, OLUWATOSIN ADESOLA (SA-C ,IMG)
Entity Type:Individual
Prefix:
First Name:OLUWATOSIN
Middle Name:ADESOLA
Last Name:AJAYI
Suffix:
Gender:M
Credentials:SA-C ,IMG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 PALMYRA LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7516
Mailing Address - Country:US
Mailing Address - Phone:386-214-4823
Mailing Address - Fax:
Practice Address - Street 1:28 PALMYRA LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7516
Practice Address - Country:US
Practice Address - Phone:386-214-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-289246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant