Provider Demographics
NPI:1972915023
Name:AYENI, OLUBUKOLA OMOBOLAJI (MD)
Entity Type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:OMOBOLAJI
Last Name:AYENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AVENUE F N
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3167
Mailing Address - Country:US
Mailing Address - Phone:979-245-2008
Mailing Address - Fax:979-314-7164
Practice Address - Street 1:2112 REGIONAL MEDICAL DR STE 1317
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-1413
Practice Address - Country:US
Practice Address - Phone:979-245-2008
Practice Address - Fax:979-314-7164
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19920207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
14377581OtherCAQH