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General NPI Number Information
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NPI Number | 1972039022
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Entity Type | Individual
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Provider Name | ADEMOLA SHOFOLUWE M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 3211 IRIS DR
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City | COVINGTON
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State | GA
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Zip | 30016-0907
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Country | US
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Telephone | 770-787-4042
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Fax | 770-922-7499
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Provider Business Mailing Address
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Address Line | 3211 IRIS DR
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City | COVINGTON
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State | GA
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Zip | 30016-0907
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Country | US
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Telephone | 770-787-4042
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Fax | 770-922-7499
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 96429
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | T7041
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License Number State | TX
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