Healthcare Provider Details

I. General information

NPI: 1922533611
Provider Name (Legal Business Name): IFEDOLAPO O. ODEBUNMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 SAINT MATTHEWS RD
ORANGEBURG SC
29118-1442
US

IV. Provider business mailing address

720 WESTVIEW DR. SW
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 803-533-2200
  • Fax:
Mailing address:
  • Phone: 404-756-1368
  • Fax: 404-756-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number83515
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: