Healthcare Provider Details

I. General information

NPI: 1174572754
Provider Name (Legal Business Name): JIMMY ADESOLA OGUNTUYO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 S 5TH ST
GADSDEN AL
35901-5101
US

IV. Provider business mailing address

PO BOX 678
GADSDEN AL
35902-0678
US

V. Phone/Fax

Practice location:
  • Phone: 256-547-3822
  • Fax: 256-547-3825
Mailing address:
  • Phone: 256-547-3822
  • Fax: 256-547-3825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26835
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: