Provider Demographics
NPI:1700829025
Name:AJAO, OLADELE O (MD)
Entity Type:Individual
Prefix:DR
First Name:OLADELE
Middle Name:O
Last Name:AJAO
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 1:2100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4701
Mailing Address - Country:US
Mailing Address - Phone:618-452-3301
Mailing Address - Fax:618-452-3312
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-452-3301
Practice Address - Fax:618-452-3312
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108133207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108133Medicaid
IL036108133Medicaid
ILH50737Medicare UPIN