Healthcare Provider Details

I. General information

NPI: 1194926469
Provider Name (Legal Business Name): OLUBUKOLA AJAYI OBIDI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLUBUKOLA BOYEWA AJAYI

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

IV. Provider business mailing address

1927 PADILLA DR
COLTON CA
92324-6611
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-4500
  • Fax:
Mailing address:
  • Phone: 305-926-9716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberARNP 9257610
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN 673401 NP 16839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: