Healthcare Provider Details

I. General information

NPI: 1093195489
Provider Name (Legal Business Name): OLUFUNKE O AJAYI MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLUFUNKE IKUOPENIKAN MBBS

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRACARE CLINIC ST CLOUD MEDICAL GROUP SOUTH 1301 33RD ST S
SAINT CLOUD MN
56301-9668
US

IV. Provider business mailing address

CENTRACARE CLINIC ST CLOUD MEDICAL GROUP SOUTH 1301 33RD ST S
SAINT CLOUD MN
56301-9668
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8181
  • Fax: 320-257-1733
Mailing address:
  • Phone: 320-251-8181
  • Fax: 320-257-1733

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 State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63031
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: