Provider Demographics
NPI:1821044959
Name:AJIBOLA, OLATUNJI (PHD)
Entity Type:Individual
Prefix:DR
First Name:OLATUNJI
Middle Name:
Last Name:AJIBOLA
Suffix:
Gender:M
Credentials:PHD
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 90153
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92427-1153
Mailing Address - Country:US
Mailing Address - Phone:909-880-0600
Mailing Address - Fax:909-473-1918
Practice Address - Street 1:1505 W HIGHLAND AVE STE 16
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1215
Practice Address - Country:US
Practice Address - Phone:909-880-0600
Practice Address - Fax:909-473-1918
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11659103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PL116590Medicare ID - Type Unspecified
S29046Medicare UPIN