Healthcare Provider Details

I. General information

NPI: 1255862058
Provider Name (Legal Business Name): ADA TOLUTOPE OGUNSIAKAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 FREEDOM DR UNIT B
CHARLOTTE NC
28208-3850
US

IV. Provider business mailing address

2550 FREEDOM DR UNIT B
CHARLOTTE NC
28208-3850
US

V. Phone/Fax

Practice location:
  • Phone: 980-533-4844
  • Fax: 980-533-4839
Mailing address:
  • Phone: 980-533-4844
  • Fax: 980-533-4839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2021-01609
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: