Healthcare Provider Details

I. General information

NPI: 1003898230
Provider Name (Legal Business Name): OLUADE A. AJAYI MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH AVE NO CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 SIXTH AVE NO CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5731
  • Fax:
Mailing address:
  • Phone: 320-252-5731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number45643
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number45643
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036070002
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: