Basic Information
| Provider Information | |||||||||
| NPI: | 1770994063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLAYANJU | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ADEFUSIKA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADEFUSIKA | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ADEJOKE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 732 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060405106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606495177 | ||||||||
| FaxNumber: | 8606434901 | ||||||||
| Practice Location | |||||||||
| Address1: | 732 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060405106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606495177 | ||||||||
| FaxNumber: | 8606434901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 61117 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 008081331 | 05 | CT | MEDICAID |