Provider Demographics
NPI:1619079621
Name:AYENI, OLAWALE (MD)
Entity Type:Individual
Prefix:
First Name:OLAWALE
Middle Name:
Last Name:AYENI
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 1:123 BROADWAY ST
Mailing Address - Street 2:P.O. BOX 288
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1022
Mailing Address - Country:US
Mailing Address - Phone:860-537-3204
Mailing Address - Fax:860-537-3208
Practice Address - Street 1:123 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1022
Practice Address - Country:US
Practice Address - Phone:860-537-3204
Practice Address - Fax:860-537-3208
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H11409Medicare UPIN