Provider Demographics
NPI:1770994063
Name:OLAYANJU, JESSICA ADEFUSIKA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ADEFUSIKA
Last Name:OLAYANJU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ADEJOKE
Other - Last Name:ADEFUSIKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:732 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5106
Mailing Address - Country:US
Mailing Address - Phone:860-649-5177
Mailing Address - Fax:860-643-4901
Practice Address - Street 1:732 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5106
Practice Address - Country:US
Practice Address - Phone:860-649-5177
Practice Address - Fax:860-643-4901
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61117207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008081331Medicaid