Basic Information
| Provider Information | |||||||||
| NPI: | 1316243868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJIBADE | ||||||||
| FirstName: | OLUWASEUN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FROSTWOOD DR STE 1.100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133386353 | ||||||||
| FaxNumber: | 7137043086 | ||||||||
| Practice Location | |||||||||
| Address1: | 11800 ASTORIA BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770896041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819296184 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 262381 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | P6942 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | P6942 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.098914 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35.098914 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0066121 | 05 | OH | MEDICAID |