Provider Demographics
NPI:1134373020
Name:BANJOKO, OPEYEMI A (MD)
Entity type:Individual
Prefix:MISS
First Name:OPEYEMI
Middle Name:A
Last Name:BANJOKO
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 1:728 N ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2335
Mailing Address - Country:US
Mailing Address - Phone:719-543-9158
Mailing Address - Fax:719-544-1958
Practice Address - Street 1:728 N ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2335
Practice Address - Country:US
Practice Address - Phone:719-543-9158
Practice Address - Fax:719-544-1958
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65703871Medicaid
CO65703871Medicaid