Provider Demographics
NPI:1992236822
Name:AYANKOLA, OLUSOLA JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:JUSTIN
Last Name:AYANKOLA
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 1:355 TOWER RD NE STE 203
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9413
Mailing Address - Country:US
Mailing Address - Phone:470-267-1580
Mailing Address - Fax:470-267-1589
Practice Address - Street 1:355 TOWER RD NE STE 203
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9413
Practice Address - Country:US
Practice Address - Phone:470-267-1580
Practice Address - Fax:470-267-1589
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT637122084P0800X
GA905202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program