Provider Demographics
NPI:1174572754
Name:OGUNTUYO, JIMMY ADESOLA (MD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:ADESOLA
Last Name:OGUNTUYO
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 678
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902-0678
Mailing Address - Country:US
Mailing Address - Phone:256-547-3822
Mailing Address - Fax:256-547-3825
Practice Address - Street 1:431 S 5TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5101
Practice Address - Country:US
Practice Address - Phone:256-547-3822
Practice Address - Fax:256-547-3825
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630412143Medicaid
AL100562Medicaid
AL630402143Medicaid
AL630409143Medicaid
AL630413143Medicaid
AL630405143Medicaid
AL630410143Medicaid
AL630411143Medicaid
AL630401143Medicaid
AL630403143Medicaid
AL630406143Medicaid
AL630408143Medicaid
AL630409143Medicaid
AL100562Medicaid