=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073578506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AYODELE A OGUNFOWORA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2006
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 WILDEWOOD PARK DR SUITE A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-788-7882
-----------------------------------------------------
Fax | 803-788-1828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 NAUTIQUE CIR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-7328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 21075
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------