Provider Demographics
NPI:1689618811
Name:AYSOLA, AGNES ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:AGNES
Middle Name:ELIZABETH
Last Name:AYSOLA
Suffix:
Gender:F
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 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP PATHOLOGY DEPT.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-4387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42392207ZB0001X, 207ZP0102X
FLME103131207ZP0102X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN258A6AYOtherBCBS
MN1692251OtherARAZ
FL0005352-00Medicaid
GA313506441AMedicaid
MNHP38358OtherHEALTHPARTNERS
IA0559724Medicaid
WI34309100Medicaid
MN1032020OtherUCARE
MN11-00245OtherMEDICA CHOICE
MN11-00014OtherMEDICA PRIMARY
MN587447500Medicaid
MN1032019OtherPREFERRED ONE
MN220000908Medicare ID - Type UnspecifiedMN MEDICARE
FLBH731ZMedicare PIN
MN220033314Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IA0559724Medicaid
MN11-00245OtherMEDICA CHOICE