Provider Demographics
NPI:1669506861
Name:OLOWOFOYEKU, BAMISEGUN VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:BAMISEGUN
Middle Name:VICTOR
Last Name:OLOWOFOYEKU
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 1:8039 GROVE HALL AVE
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3731
Mailing Address - Country:US
Mailing Address - Phone:704-482-1450
Mailing Address - Fax:
Practice Address - Street 1:508 EASTWAY DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205
Practice Address - Country:US
Practice Address - Phone:704-248-0246
Practice Address - Fax:704-467-8351
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2020-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25939207R00000X, 208600000X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C86380Medicare UPIN