Provider Demographics
NPI:1265929418
Name:TIJANI, OLUSOLA (MD)
Entity type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:
Last Name:TIJANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:OLUSOLA
Other - Middle Name:ABIGAIL
Other - Last Name:KOMOLAFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OLUSOLA KOMOLAFE
Mailing Address - Street 1:6300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4037
Mailing Address - Country:US
Mailing Address - Phone:225-658-4000
Mailing Address - Fax:
Practice Address - Street 1:6110 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4079
Practice Address - Country:US
Practice Address - Phone:225-570-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA329612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program