Provider Demographics
NPI:1598414153
Name:ADOMAYI, OLUSOLA JAMES
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:JAMES
Last Name:ADOMAYI
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 1:10694 IRONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5812
Mailing Address - Country:US
Mailing Address - Phone:651-703-7359
Mailing Address - Fax:
Practice Address - Street 1:10694 IRONWOOD CT
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-5812
Practice Address - Country:US
Practice Address - Phone:651-703-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF196096181816OtherDMV