Basic Information
| Provider Information | |||||||||
| NPI: | 1497750277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLAJI | ||||||||
| FirstName: | OLUBUKOLA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7726 GUNSTON PLZ UNIT 1164 | ||||||||
| Address2: | |||||||||
| City: | LORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221998054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177737014 | ||||||||
| FaxNumber: | 8443731885 | ||||||||
| Practice Location | |||||||||
| Address1: | 8700 SUDLEY RD | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201104418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033965292 | ||||||||
| FaxNumber: | 7033965297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101261217 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | M3919 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 0101261217 | VA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 5461151 | 01 | TX | AETNA | OTHER | 0284562 | 05 | OH | MEDICAID | 180925301 | 05 | TX | MEDICAID | 8P5794 | 01 | TX | BCBS | OTHER |