Provider Demographics
NPI:1972039022
Name:SHOFOLUWE, ADEMOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEMOLA
Middle Name:
Last Name:SHOFOLUWE
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 1:3211 IRIS DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-0907
Mailing Address - Country:US
Mailing Address - Phone:770-787-4042
Mailing Address - Fax:770-922-7499
Practice Address - Street 1:3211 IRIS DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-0907
Practice Address - Country:US
Practice Address - Phone:770-787-4042
Practice Address - Fax:770-922-7499
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96429207X00000X
TXT7041390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program