Provider Demographics
NPI:1902862360
Name:ROSANWO, AYODEJI OLUSILE (MD)
Entity Type:Individual
Prefix:
First Name:AYODEJI
Middle Name:OLUSILE
Last Name:ROSANWO
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:PO BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-863-9850
Mailing Address - Fax:704-863-9851
Practice Address - Street 1:101 E WT HARRIS BLVD
Practice Address - Street 2:BUILDING 1000 - SUITE 1110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-863-9850
Practice Address - Fax:704-863-9851
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043372A207QG0300X
NC2014-01481207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200314410Medicaid
NC1902862360Medicaid
SCNC2346Medicaid
NCNCL484C904Medicare PIN
NC1902862360Medicaid
IN150640EMedicare PIN
SCNC2346Medicaid