MEDICARE: ANDREA BAOWANG AJAYI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	A72668	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164413472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA BAOWANG AJAYI MD

Provider Business Mailing Address
First Line	:	5714 EASTVIEW DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95212-2526
Country	:	US
Telephone Number	:	209-747-5918
Fax Number	:	209-931-1285

Provider Business Practice Location Address
First Line	:	1800 HARRISON ST
Second Line	:	7TH FLOOR
City	:	OAKLAND
State	:	CA
Zip	:	94612-3466
Country	:	US
Telephone Number	:	510-625-6262
Fax Number	:	510-625-6226

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/06/2009

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