Provider Demographics
NPI:1821084054
Name:OYEYIPO-AJUMOBI, BOLANLE TOKUNBO (MD)
Entity Type:Individual
Prefix:DR
First Name:BOLANLE
Middle Name:TOKUNBO
Last Name:OYEYIPO-AJUMOBI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BOLANLE
Other - Middle Name:TOKUNBO
Other - Last Name:OYEYIPO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1717 E DATE PL
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4428
Mailing Address - Country:US
Mailing Address - Phone:909-740-5885
Mailing Address - Fax:
Practice Address - Street 1:1717 E DATE PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4428
Practice Address - Country:US
Practice Address - Phone:909-740-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92030207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABO9370482OtherDEA
CABO9370482OtherDEA