Provider Demographics
NPI:1326132804
Name:SOYODE-ETOMI, OLATOKUNBO EFUNSAMI (MD)
Entity Type:Individual
Prefix:DR
First Name:OLATOKUNBO
Middle Name:EFUNSAMI
Last Name:SOYODE-ETOMI
Suffix:
Gender:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 N CASWELL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2403
Practice Address - Country:US
Practice Address - Phone:704-384-7980
Practice Address - Fax:704-384-7985
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300327207R00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930894Medicaid
NC2192879BMedicare ID - Type Unspecified
NC8930894Medicaid