Healthcare Provider Details

I. General information

NPI: 1366920761
Provider Name (Legal Business Name): AYOOLA WALEY OLAJIDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WHITEHALL DR
ST AUGUSTINE FL
32086-5269
US

IV. Provider business mailing address

1302 RIVER ST
PALATKA FL
32177-5042
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2782
  • Fax: 904-829-2494
Mailing address:
  • Phone: 386-328-0108
  • Fax: 386-325-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number021031
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: