Healthcare Provider Details

I. General information

NPI: 1427462605
Provider Name (Legal Business Name): AYOOLA OLUKUNMI OLADEJO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SCHOENERSVILLE RD
BETHLEHEM PA
18017-7300
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 484-884-9677
  • Fax:
Mailing address:
  • Phone: 570-326-8723
  • Fax: 570-326-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD468111
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101259820
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD468111
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101259820
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: