Basic Information
| Provider Information | |||||||||
| NPI: | 1992851224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJIBOLA | ||||||||
| FirstName: | OLAKUNLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14690 SPRING HILL DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346098102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522775348 | ||||||||
| FaxNumber: | 3526062857 | ||||||||
| Practice Location | |||||||||
| Address1: | 11910 LITTLE RD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346541013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278632655 | ||||||||
| FaxNumber: | 7278613435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2007 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 64750 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME112602 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 828672224A | 05 | GA | MEDICAID | 025027800 | 05 | FL | MEDICAID | 828672224B | 05 | GA | MEDICAID | 202I085802 | 01 | GA | MEDICARE | OTHER |