Healthcare Provider Details

I. General information

NPI: 1417995978
Provider Name (Legal Business Name): BAMIDELE ANUOLUWA AJAYI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 10/26/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13425 HOOVER CREEK BLVD STE 101
CHARLOTTE NC
28273
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1246
  • Fax: 704-384-6072
Mailing address:
  • Phone: 704-384-1246
  • Fax: 704-384-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number259100
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2016-00983
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number259100
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2016-00983
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: