Provider Demographics
NPI:1174524409
Name:OLAJIDE, OMOLOLA (MD)
Entity type:Individual
Prefix:DR
First Name:OMOLOLA
Middle Name:
Last Name:OLAJIDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 15TH ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-1000
Mailing Address - Fax:304-691-1693
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-3662
Practice Address - Country:US
Practice Address - Phone:615-936-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN66783207R00000X, 207RE0101X
WV23600207RE0101X
AZ33613207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ933607Medicaid
WV3810015612Medicaid
WV3810015612Medicaid
AZI31894Medicare UPIN
WVOL4275631Medicare PIN