Healthcare Provider Details

I. General information

NPI: 1457948978
Provider Name (Legal Business Name): OMOKAYODE AKANJI OGUNDIMU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 PARK HOLLOW WAY
LAWRENCEVILLE GA
30043-3869
US

IV. Provider business mailing address

1027 PARK HOLLOW WAY
LAWRENCEVILLE GA
30043-3869
US

V. Phone/Fax

Practice location:
  • Phone: 678-234-4362
  • Fax:
Mailing address:
  • Phone: 678-234-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: