Provider Demographics
NPI:1306422415
Name:AGBOOLA, OLAYINKA JOHNSON (MD, MPH)
Entity type:Individual
Prefix:
First Name:OLAYINKA
Middle Name:JOHNSON
Last Name:AGBOOLA
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BEAVER ST APT B
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-3269
Mailing Address - Country:US
Mailing Address - Phone:860-515-1873
Mailing Address - Fax:
Practice Address - Street 1:8081 INNOVATION PARK DR STE 700
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101281697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine