Provider Demographics
NPI:1821014226
Name:ASIYANBOLA, BOLANLE A (MD)
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:A
Last Name:ASIYANBOLA
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 1:1005 DR DB TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3501
Mailing Address - Country:US
Mailing Address - Phone:615-327-5944
Mailing Address - Fax:615-327-5597
Practice Address - Street 1:4140 FERNCREEK DR
Practice Address - Street 2:SUITE 601
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2563
Practice Address - Country:US
Practice Address - Phone:910-485-3880
Practice Address - Fax:910-485-5341
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD64664208600000X
TN59311208600000X
MA256906208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD191982YVEMedicare PIN