1720139645 NPI number — DR. ADEDAPO M ODUWOLE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720139645 NPI number — DR. ADEDAPO M ODUWOLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODUWOLE
Provider First Name:
ADEDAPO
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
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:
ADEDAOP
Provider Other First Name:
ODUWOLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720139645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1203 48TH AVE N
Provider Second Line Business Practice Location Address:
202
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-5425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-2576
Provider Business Practice Location Address Fax Number:
843-449-6851
Provider Enumeration Date:
01/16/2007

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: 2084P0800X , with the licence number:  43425 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 31507 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31507 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34116200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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