Basic Information
| Provider Information | |||||||||
| NPI: | 1578552477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADETUNJI | ||||||||
| FirstName: | OLAYIWOLA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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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 | 46321 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 46321 | MN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2014147 | 01 | ARAZ GROUP/AMERICA'S PPO | OTHER | 1578552477 | 05 | MN | MEDICAID | 660903100 | 05 | MN | MEDICAID | 1040299 | 01 | PREFERRED ONE | OTHER | P00081376 | 01 | RR MEDICARE | OTHER | 0406311 | 01 | MEDICA HEALTH PLANS | OTHER | 706S1AD | 01 | BLUE CROSS BLUE SHIELD | OTHER | HP40371 | 01 | HEALTH PARTNERS | OTHER | 131162 | 01 | U-CARE | OTHER | 2157310 | 01 | FIRST HEALTH PLAN | OTHER | 660903100 | 01 | MEDICAL ASSISTANCE | OTHER |