Basic Information
| Provider Information | |||||||||
| NPI: | 1558570952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OGUNTOYINBO | ||||||||
| FirstName: | MOJIROLA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299362605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 552 STINEY RD | ||||||||
| Address2: | |||||||||
| City: | HARDEEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299275228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437842182 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5401576 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP4216 | 05 | SC | MEDICAID |