Healthcare Provider Details

I. General information

NPI: 1013901222
Provider Name (Legal Business Name): OLAWALE ADETAYO MORAFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2693 UNION AVENUE EXT SUITE 100
MEMPHIS TN
38112-4403
US

IV. Provider business mailing address

2693 UNION AVENUE EXT SUITE 100
MEMPHIS TN
38112-4403
US

V. Phone/Fax

Practice location:
  • Phone: 901-722-0088
  • Fax: 901-722-0082
Mailing address:
  • Phone: 901-722-0088
  • Fax: 901-722-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36735
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: