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 1:500 ARCHDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4217
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:
Practice Address - Street 1:549 COX RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0628
Practice Address - Country:US
Practice Address - Phone:704-865-1558
Practice Address - Fax:704-865-9908
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300327251S00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930894Medicaid
NC2192879BMedicare ID - Type Unspecified
NC8930894Medicaid