Provider Demographics
NPI:1205808318
Name:OLADELE-AJOSE, OLUFEMI TAIWO (MD)
Entity type:Individual
Prefix:DR
First Name:OLUFEMI
Middle Name:TAIWO
Last Name:OLADELE-AJOSE
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 1:347 COUNTY ROAD 8341
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-3304
Mailing Address - Country:US
Mailing Address - Phone:319-850-0874
Mailing Address - Fax:
Practice Address - Street 1:2111 E DENMAN AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-6243
Practice Address - Country:US
Practice Address - Phone:936-244-0659
Practice Address - Fax:936-899-7243
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9394207P00000X, 207R00000X
IA32077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2165803Medicaid
TXTXB149485OtherPROVIDER NUMBER
49346OtherWELLMARK
G62239Medicare UPIN
IA2165803Medicaid
TXTXB149485OtherPROVIDER NUMBER