Provider Demographics
NPI:1598792657
Name:AIYENOWO, JOSEPH O (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:O
Last Name:AIYENOWO
Suffix:
Gender:M
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:PO BOX 609
Mailing Address - Street 2:705 E RANDALL
Mailing Address - City:HESSTON
Mailing Address - State:KS
Mailing Address - Zip Code:67062
Mailing Address - Country:US
Mailing Address - Phone:620-327-2440
Mailing Address - Fax:620-327-2062
Practice Address - Street 1:19401 40TH AVE W STE 230
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5675
Practice Address - Country:US
Practice Address - Phone:425-744-7153
Practice Address - Fax:425-744-7123
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-27421207Q00000X
KS0427421208000000X
WAMD60992612208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100381040CMedicaid
H29554Medicare UPIN
KS100381040CMedicaid