Healthcare Provider Details

I. General information

NPI: 1467711960
Provider Name (Legal Business Name): AYODEJI OLAREWAJU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 W 3RD AVE
ALBANY GA
31701
US

IV. Provider business mailing address

500 W 3RD AVE STE 101
ALBANY GA
31701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 229-312-1000
  • Fax:
Mailing address:
  • Phone: 229-312-5800
  • Fax: 908-522-0804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number137476
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number137476
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number077861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: