Provider Demographics
NPI:1972701217
Name:AJAYI, OLUYEMI ADEBOWALE (MBBS)
Entity Type:Individual
Prefix:
First Name:OLUYEMI
Middle Name:ADEBOWALE
Last Name:AJAYI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:937-352-3580
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:937-352-3580
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090323208M00000X, 207R00000X
MN55013208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00446750OtherRAILROAD MEDICARE
OH2793080Medicaid
OH000000530884OtherANTHEM
MN1972701217Medicaid
OH9164059OtherAETNA
MN1972701217Medicaid
OH4219891Medicare PIN