Provider Demographics
NPI:1720139645
Name:ODUWOLE, ADEDAPO M (MD)
Entity type:Individual
Prefix:DR
First Name:ADEDAPO
Middle Name:M
Last Name:ODUWOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ODUWOLE
Other - Middle Name:M
Other - Last Name:ADEDAOP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1203 48TH AVE N
Mailing Address - Street 2:202
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5425
Mailing Address - Country:US
Mailing Address - Phone:843-449-2576
Mailing Address - Fax:843-449-6851
Practice Address - Street 1:1203 48TH AVE N
Practice Address - Street 2:202
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5425
Practice Address - Country:US
Practice Address - Phone:843-449-2576
Practice Address - Fax:843-449-6851
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI434252084P0800X
SC315072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC31507Medicaid
WI34116200Medicaid
G97612Medicare UPIN
WI34116200Medicaid
WI849080020Medicare PIN