Healthcare Provider Details

I. General information

NPI: 1285167759
Provider Name (Legal Business Name): OLABODE AGAJA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S CLEARVIEW PKWY
JEFFERSON LA
70121-1015
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-736-4800
  • Fax: 504-736-4810
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number327774
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: