Healthcare Provider Details

I. General information

NPI: 1902887706
Provider Name (Legal Business Name): AYOTUNDE KOFOWOROLA AYODELE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 MEMORIAL DR
CERES CA
95307-1827
US

IV. Provider business mailing address

430 S HERLONG AVE SUITE 104
ROCK HILL SC
29732-9446
US

V. Phone/Fax

Practice location:
  • Phone: 209-383-7441
  • Fax:
Mailing address:
  • Phone: 803-980-6610
  • Fax: 803-980-6162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number199147
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberSC 21581
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21581
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: