Provider Demographics
NPI:1073578506
Name:OGUNFOWORA, AYODELE A (MD)
Entity Type:Individual
Prefix:DR
First Name:AYODELE
Middle Name:A
Last Name:OGUNFOWORA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 NAUTIQUE CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 WILDEWOOD PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4300
Practice Address - Country:US
Practice Address - Phone:803-788-7882
Practice Address - Fax:803-788-1828
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC210752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC210756Medicaid
H12178Medicare UPIN