Provider Demographics
NPI:1104544824
Name:MAKINDE, OLUWAFUNMILAYO
Entity type:Individual
Prefix:
First Name:OLUWAFUNMILAYO
Middle Name:
Last Name:MAKINDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 AUSTIN THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1681
Mailing Address - Country:US
Mailing Address - Phone:818-795-6255
Mailing Address - Fax:
Practice Address - Street 1:4140 MOORE RD STE B114
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7157
Practice Address - Country:US
Practice Address - Phone:678-866-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA460548974OtherMED SPA