Basic Information
Provider Information | |||||||||
NPI: | 1346435815 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AJALA | ||||||||
FirstName: | MOYOSADE | ||||||||
MiddleName: | ADEYINKA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 E JOHN CARPENTER FWY | ||||||||
Address2: | SUITE 850 | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750622727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729573000 | ||||||||
FaxNumber: | 9729573005 | ||||||||
Practice Location | |||||||||
Address1: | 410 E PIONEER PKWY | ||||||||
Address2: | SUITE 300 | ||||||||
City: | GRAND PRAIRIE | ||||||||
State: | TX | ||||||||
PostalCode: | 750514983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4697331890 | ||||||||
FaxNumber: | 4697331894 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2007 | ||||||||
LastUpdateDate: | 09/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10027990 | TX | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | N8264 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.