Provider Demographics
NPI:1457316168
Name:ETUMADU, AJIKE OGUNSULIRE
Entity Type:Individual
Prefix:
First Name:AJIKE
Middle Name:OGUNSULIRE
Last Name:ETUMADU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:CMC ANNEX 1ST FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-01885208M00000X, 207R00000X, 207RG0300X
SC51653208M00000X
PAMD436839207R00000X
MA224961207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1553Medicaid
NC5919791Medicaid
MA000000032021OtherHEALTHNET
MA0036710OtherNHP
MA04-09491OtherEVERCARE
MAAA40795OtherHARVARD PILGRIM #
MAMO0598524AOtherCSR #
SCNC1553Medicaid
MABO9365479OtherPROVIDER DEA #
MA1310097Medicaid
MA967638OtherNETWORK HEALTH #
MAJ29393OtherBC/BS
NCNC6167BMedicare PIN
MA1310097Medicaid
NC5919791Medicaid
MABO9365479OtherPROVIDER DEA #
DE130555ZAG8Medicare PIN