Provider Demographics
NPI:1376552141
Name:OLAJIDE, BOLANLE ABIMBOLA (MD)
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:ABIMBOLA
Last Name:OLAJIDE
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 1:1643 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1748
Mailing Address - Country:US
Mailing Address - Phone:718-690-5236
Mailing Address - Fax:718-771-8450
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-771-8435
Practice Address - Fax:718-771-8450
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210092208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01878739Medicaid
NY01878739Medicaid