Provider Demographics
NPI:1104877984
Name:AJAYI, ADEBOWALE I (MD)
Entity type:Individual
Prefix:
First Name:ADEBOWALE
Middle Name:I
Last Name:AJAYI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENBELT RD
Mailing Address - Street 2:SUITE M-18
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2354
Mailing Address - Country:US
Mailing Address - Phone:301-313-9013
Mailing Address - Fax:301-313-9015
Practice Address - Street 1:6201 GREENBELT RD
Practice Address - Street 2:SUITE M-18
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2354
Practice Address - Country:US
Practice Address - Phone:301-313-9013
Practice Address - Fax:301-313-9015
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD045217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00379380OtherRAILROAD MED
MD125931800Medicaid
MD75859903OtherBLUE SHIELD
MDP00379380OtherRAILROAD MED
DC056251Medicare PIN
MD761LE591Medicare PIN