Provider Demographics
NPI:1316991748
Name:OJO, OLUFUNSO A (MD)
Entity type:Individual
Prefix:
First Name:OLUFUNSO
Middle Name:A
Last Name:OJO
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:PO BOX 451228
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31145-9228
Mailing Address - Country:US
Mailing Address - Phone:770-484-3092
Mailing Address - Fax:770-484-3096
Practice Address - Street 1:8225 MALL PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-6946
Practice Address - Country:US
Practice Address - Phone:770-484-3092
Practice Address - Fax:770-484-3096
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054004207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA619739917BMedicaid
GA619739917BMedicaid
GA11SCFWSMedicare ID - Type Unspecified