Provider Demographics
NPI:1902121007
Name:BOLAJI, OLADIRAN
Entity type:Individual
Prefix:
First Name:OLADIRAN
Middle Name:
Last Name:BOLAJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 W 125TH ST
Mailing Address - Street 2:12 FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4436
Mailing Address - Country:US
Mailing Address - Phone:212-961-8723
Mailing Address - Fax:212-866-2760
Practice Address - Street 1:163 W 125TH ST
Practice Address - Street 2:12 FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4436
Practice Address - Country:US
Practice Address - Phone:212-961-8723
Practice Address - Fax:212-866-2760
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY662825163W00000X
NY293266164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1902121007Medicaid