Provider Demographics
NPI:1215501812
Name:AJADI, EBUNOLUWA (MD)
Entity type:Individual
Prefix:
First Name:EBUNOLUWA
Middle Name:
Last Name:AJADI
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 1:1906 BELLEVIEW AVE SE
Mailing Address - Street 2:MEDICAL EDUCATION BUILDING FL 3
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014
Mailing Address - Country:US
Mailing Address - Phone:859-230-6595
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014
Practice Address - Country:US
Practice Address - Phone:859-230-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-06-07
Deactivation Date:2023-03-24
Deactivation Code:
Reactivation Date:2023-06-07
Provider Licenses
StateLicense IDTaxonomies
VA0116035302208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program