Provider Demographics
NPI:1982632063
Name:AJAGBE, OLUKUNLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUKUNLE
Middle Name:A
Last Name:AJAGBE
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 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-1570
Mailing Address - Fax:601-249-1544
Practice Address - Street 1:212 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2706
Practice Address - Country:US
Practice Address - Phone:601-249-1570
Practice Address - Fax:601-249-1544
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19332207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01783376Medicaid
MS01783376Medicaid
MS110001992Medicare PIN