Healthcare Provider Details

I. General information

NPI: 1164757936
Provider Name (Legal Business Name): OLUTOYIN OGUNDIPE MD, FWACS, FMCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 ADEYERI CLOSE OFF OPEBI STREET
IKEJA LAGOS
100001
NG

IV. Provider business mailing address

5921 VISTA VERDE CT
CHARLOTTE NC
28273-6976
US

V. Phone/Fax

Practice location:
  • Phone: 01123418922647
  • Fax:
Mailing address:
  • Phone: 704-583-1290
  • Fax: 866-262-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2897
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: