Provider Demographics
NPI:1750161675
Name:AYODELE, OLAWALE
Entity type:Individual
Prefix:
First Name:OLAWALE
Middle Name:
Last Name:AYODELE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E ABRAM ST STE 14
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-1206
Mailing Address - Country:US
Mailing Address - Phone:817-903-3353
Mailing Address - Fax:
Practice Address - Street 1:1751 W WALKER ST APT 10101
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4299
Practice Address - Country:US
Practice Address - Phone:936-777-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39799226172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver