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General NPI Number Information
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NPI Number | 1730389198
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Entity Type | Individual
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Provider Name | FOLUSHO EVERTON OGUNFIDITIMI PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 07/23/2007
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Provider Practice Location Address
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Address Line | HENRY FORD HEALTH SYSTEM 2799 WEST GRAND BLVD.
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City | DETROIT
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State | MI
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Zip | 48202
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Country | US
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Telephone | 313-916-9971
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Fax | 313-916-2086
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Provider Business Mailing Address
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Address Line | 3334 GOAT FELL
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City | ANN ARBOR
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State | MI
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Zip | 48108-2087
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Country | US
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Telephone | 313-916-9971
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Fax | 313-916-2086
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 5601003120
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License Number State | MI
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