Provider Demographics
NPI:1952673287
Name:OLUFEMI OLADELE-AJOSE MD PC
Entity Type:Organization
Organization Name:OLUFEMI OLADELE-AJOSE MD PC
Other - Org Name:NACOGDOCHES INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:T
Authorized Official - Last Name:OLADELE-AJOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-2250
Mailing Address - Street 1:4848 NE STALLINGS DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1208
Mailing Address - Country:US
Mailing Address - Phone:936-560-2250
Mailing Address - Fax:936-560-2316
Practice Address - Street 1:4848 NE STALLINGS DR STE 103
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1208
Practice Address - Country:US
Practice Address - Phone:936-560-2250
Practice Address - Fax:936-560-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G62239Medicare UPIN
IA49401Medicare PIN