Provider Demographics
NPI:1457988941
Name:BANGOLO, AYRTON ILOLO (MD)
Entity Type:Individual
Prefix:
First Name:AYRTON
Middle Name:ILOLO
Last Name:BANGOLO
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 1:9006 CROWNE SPRINGS CIR UNIT 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-8133
Mailing Address - Country:US
Mailing Address - Phone:217-291-4048
Mailing Address - Fax:
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:201-710-2756
Practice Address - Fax:201-758-2740
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program