MEDICARE: DR. ADEDAPO M ODUWOLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	43425	WI
2	2084P0800X	Psychiatry Physician	31507	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720139645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADEDAPO M ODUWOLE MD

Provider Business Mailing Address
First Line	:	1203 48TH AVE N
Second Line	:	202
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5425
Country	:	US
Telephone Number	:	843-449-2576
Fax Number	:	843-449-6851

Provider Business Practice Location Address
First Line	:	1203 48TH AVE N
Second Line	:	202
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5425
Country	:	US
Telephone Number	:	843-449-2576
Fax Number	:	843-449-6851

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	03/21/2014

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Directions to “ DR. ADEDAPO M ODUWOLE MD” Practice Location

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