Provider Demographics
NPI:1083466403
Name:AJIBOLA, OPEYEMI BOYEDE
Entity type:Individual
Prefix:
First Name:OPEYEMI
Middle Name:BOYEDE
Last Name:AJIBOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33300 EGYPT LN
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-2739
Mailing Address - Country:US
Mailing Address - Phone:936-650-7553
Mailing Address - Fax:
Practice Address - Street 1:33300 EGYPT LN STE C500
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2873
Practice Address - Country:US
Practice Address - Phone:281-570-5078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
TX1156415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care