Basic Information
| Provider Information | |||||||||
| NPI: | 1215468541 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | AJAGUNNA | ||||||||
| FirstName: | ADEBUKOLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 FORT CAMPBELL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422409339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708858445 | ||||||||
| FaxNumber: | 2708869106 | ||||||||
| Practice Location | |||||||||
| Address1: | 4235 FORT CAMPBELL BLVD | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422409339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708858445 | ||||||||
| FaxNumber: | 2708869106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 60519 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 56663 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100816390 | 05 | KY | MEDICAID |