MEDICARE: OLUWATOSIN B AJIBOLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1177043	TX

General Provider Information

NPI Number	:	1063230464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLUWATOSIN B AJIBOLA

Provider Business Mailing Address
First Line	:	4927 LAKE RIDGE PKWY STE 148
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3000
Country	:	US
Telephone Number	:	972-217-4203
Fax Number	:

Provider Business Practice Location Address
First Line	:	4927 LAKE RIDGE PKWY STE 148
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3000
Country	:	US
Telephone Number	:	972-217-4203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	09/04/2025

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Directions to “ OLUWATOSIN B AJIBOLA ” Practice Location

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