Provider Demographics
NPI:1578552477
Name:ADETUNJI, OLAYIWOLA R (MBBS)
Entity Type:Individual
Prefix:
First Name:OLAYIWOLA
Middle Name:R
Last Name:ADETUNJI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46321207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2014147OtherARAZ GROUP/AMERICA'S PPO
MN1578552477Medicaid
MN660903100Medicaid
1040299OtherPREFERRED ONE
P00081376OtherRR MEDICARE
0406311OtherMEDICA HEALTH PLANS
706S1ADOtherBLUE CROSS BLUE SHIELD
HP40371OtherHEALTH PARTNERS
131162OtherU-CARE
2157310OtherFIRST HEALTH PLAN
660903100OtherMEDICAL ASSISTANCE
MN110009441Medicare PIN
HP40371OtherHEALTH PARTNERS