Provider Demographics
NPI:1386726503
Name:ILEDARE, OLAJUNMOKE JOYCE (PT)
Entity type:Individual
Prefix:MRS
First Name:OLAJUNMOKE
Middle Name:JOYCE
Last Name:ILEDARE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:JOYCE
Other - Middle Name:O
Other - Last Name:ILEDARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1121 N LOBDELL AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-2235
Mailing Address - Country:US
Mailing Address - Phone:225-926-2645
Mailing Address - Fax:
Practice Address - Street 1:1121 N LOBDELL AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-2235
Practice Address - Country:US
Practice Address - Phone:225-926-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01557F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551970Medicaid
LA5X687Medicare PIN