Provider Demographics
NPI:1902887706
Name:AYODELE, AYOTUNDE KOFOWOROLA (MD)
Entity Type:Individual
Prefix:DR
First Name:AYOTUNDE
Middle Name:KOFOWOROLA
Last Name:AYODELE
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 1:430 S HERLONG AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9446
Mailing Address - Country:US
Mailing Address - Phone:803-980-6610
Mailing Address - Fax:803-980-6162
Practice Address - Street 1:430 S HERLONG AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9446
Practice Address - Country:US
Practice Address - Phone:803-980-6610
Practice Address - Fax:803-980-6162
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 21581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2934Medicaid
SCGP2934Medicaid