Provider Demographics
NPI:1639519523
Name:AYOOLA, ROTIMI ROYCE (MD)
Entity Type:Individual
Prefix:
First Name:ROTIMI
Middle Name:ROYCE
Last Name:AYOOLA
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 1:190 CAMPUS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2872
Mailing Address - Country:US
Mailing Address - Phone:540-667-1244
Mailing Address - Fax:540-667-3086
Practice Address - Street 1:190 CAMPUS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2872
Practice Address - Country:US
Practice Address - Phone:540-667-1244
Practice Address - Fax:540-667-3086
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268231207RG0100X
GA006153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639519523Medicaid