Healthcare Provider Details

I. General information

NPI: 1790745495
Provider Name (Legal Business Name): JOEL A ONAFOWOKAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 LATROBE DR
CHARLOTTE NC
28211-1388
US

IV. Provider business mailing address

3626 LATROBE DR
CHARLOTTE NC
28211-1388
US

V. Phone/Fax

Practice location:
  • Phone: 704-366-7182
  • Fax: 704-366-7184
Mailing address:
  • Phone: 704-366-7182
  • Fax: 704-366-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number200401292
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number61-2351
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27357
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200401292
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: