Healthcare Provider Details

I. General information

NPI: 1013658038
Provider Name (Legal Business Name): BOLAJI SOJI OJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 MOON RD
PLAINFIELD IN
46168-8757
US

IV. Provider business mailing address

7210 VILLAGE PARKWAY DR APT 5
INDIANAPOLIS IN
46254-4352
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-2513
  • Fax:
Mailing address:
  • Phone: 317-285-9081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02220900
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: