Provider Demographics
NPI:1790745495
Name:ONAFOWOKAN, JOEL A (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:A
Last Name:ONAFOWOKAN
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 1:3626 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1388
Mailing Address - Country:US
Mailing Address - Phone:704-366-7182
Mailing Address - Fax:704-366-7184
Practice Address - Street 1:3626 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1388
Practice Address - Country:US
Practice Address - Phone:704-366-7182
Practice Address - Fax:704-366-7184
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004012922084A0401X, 207R00000X
NC61-23512084A0401X
SC27357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1406KOtherBCBS
NC5902366Medicaid
NC1406KOtherBCBS
NCI45100Medicare UPIN