Healthcare Provider Details

I. General information

NPI: 1073578506
Provider Name (Legal Business Name): AYODELE A OGUNFOWORA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

106 NAUTIQUE CIR
COLUMBIA SC
29229-7328
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-7882
  • Fax: 803-788-1828
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number21075
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: