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General NPI Number Information
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NPI Number | 1730229683
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Entity Type | Organization
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Legal Business Name | MEDOGUN PA
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Dates
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Enumeration Date | 02/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 120 WILDEWOOD PARK DR SUITE A
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City | COLUMBIA
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State | SC
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Zip | 29223-4300
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Country | US
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Telephone | 803-788-7882
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Fax |
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Provider Business Mailing Address
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Address Line | 120 WILDEWOOD PARK DR SUITE A
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City | COLUMBIA
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State | SC
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Zip | 29223-4300
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Country | US
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Telephone | 803-788-7882
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. AYODELE ADETOKUNBO OGUNFOWORA
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Credential | M.D.
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Telephone | 803-788-7882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 21075
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License Number State | SC
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