Healthcare Provider Details

I. General information

NPI: 1376683391
Provider Name (Legal Business Name): MEDOGUN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WILDEWOOD PARK DR SUITE B
COLUMBIA SC
29223-4300
US

IV. Provider business mailing address

120 WILDEWOOD PARK DR SUITE B
COLUMBIA SC
29223-4300
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-7882
  • Fax: 803-788-7818
Mailing address:
  • Phone: 803-788-7882
  • Fax: 803-788-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number21514
License Number StateSC

VIII. Authorized Official

Name: DR. MOJIBOLA OLAYINKA SOLAJA
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 803-788-7882