Provider Demographics
NPI:1477041085
Name:TAIWO, OLUWABUKOLA IBUKUNOLUWA (MD)
Entity Type:Individual
Prefix:
First Name:OLUWABUKOLA
Middle Name:IBUKUNOLUWA
Last Name:TAIWO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OLUWABUKOLA
Other - Middle Name:IBUKUNOLUWA
Other - Last Name:ADENIYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1199 PRINCE AVE
Mailing Address - Street 2:#70
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 PRINCE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC85752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program