Healthcare Provider Details

I. General information

NPI: 1528196227
Provider Name (Legal Business Name): DEJI O OKUBOYE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MACEDONIA CHURCH ROAD
TAYLORSVILLE NC
28681-8414
US

IV. Provider business mailing address

PO BOX 890273
CHARLOTTE NC
28289-0273
US

V. Phone/Fax

Practice location:
  • Phone: 828-632-7076
  • Fax: 828-632-7028
Mailing address:
  • Phone: 828-632-7076
  • Fax: 828-632-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9863
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008-00736
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: