1194081851 NPI number — ADETOKUNBO AWOJULU MD

Table of content: ADETOKUNBO AWOJULU MD (NPI 1194081851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194081851 NPI number — ADETOKUNBO AWOJULU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AWOJULU
Provider First Name:
ADETOKUNBO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194081851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8818
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31095-8818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-333-6468
Provider Business Mailing Address Fax Number:
478-953-6727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 MARGIE DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-333-6432
Provider Business Practice Location Address Fax Number:
478-302-0643
Provider Enumeration Date:
04/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME121902 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 84511 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003228382A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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