Provider Demographics
NPI:1942530266
Name:ODUOLA, AYODEJI (MD)
Entity Type:Individual
Prefix:DR
First Name:AYODEJI
Middle Name:
Last Name:ODUOLA
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2600 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3055
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-838-4698
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252866207R00000X
ORMD188608208M00000X
390200000X
IN01071055A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000766029OtherANTHEM PROVIDER NUMBER
IN201063890Medicaid
INP01090903Medicare PIN
INM400069359Medicare PIN