Provider Demographics
NPI:1932155868
Name:OLUSANYA, AYODELE ADELEKE (MD)
Entity Type:Individual
Prefix:
First Name:AYODELE
Middle Name:ADELEKE
Last Name:OLUSANYA
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 1:42 WILLOW GREEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 DAVY CROCKETT MALL
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-2934
Practice Address - Country:US
Practice Address - Phone:731-855-2803
Practice Address - Fax:731-855-1746
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37856207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3895683Medicaid
TN3895684Medicaid
TN4106219OtherBCBS
TN4109887OtherBCBS
TN4139060OtherBCBS
TN3895681Medicaid
TNP00376124OtherRR MEDICARE
TNP00380502OtherRAILROAD MEDICARE
TN3895682Medicaid
TN3895687Medicaid
TN4139060OtherBCBS
TN3891684Medicare ID - Type Unspecified
TN3895682Medicare PIN
TNH95679Medicare UPIN
TN3895687Medicaid
TN3895683Medicare PIN