Healthcare Provider Details

I. General information

NPI: 1972701217
Provider Name (Legal Business Name): OLUYEMI ADEBOWALE AJAYI MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH AVE N CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 SIXTH AVE N CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 937-352-3580
Mailing address:
  • Phone: 320-251-2700
  • Fax: 937-352-3580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35090323
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35090323
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number55013
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: