Provider Demographics
NPI:1417509191
Name:OLULORO, AYODEJI MOSES
Entity Type:Individual
Prefix:MR
First Name:AYODEJI
Middle Name:MOSES
Last Name:OLULORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 BLUE HERON PASS
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-2399
Mailing Address - Country:US
Mailing Address - Phone:404-822-0318
Mailing Address - Fax:770-439-8171
Practice Address - Street 1:3111 BLUE HERON PASS
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2399
Practice Address - Country:US
Practice Address - Phone:404-822-0318
Practice Address - Fax:770-439-8171
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF02190775163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice