Basic Information
| Provider Information | |||||||||
| NPI: | 1255573960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYANLEKE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MOSADOLUWA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AYANLEKE | ||||||||
| OtherFirstName: | OMOBAYONLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 600352 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322600352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7865403940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME109811 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35.093062 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 35-093062 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 65990 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2946432 | 05 | OH | MEDICAID |