MEDICARE: DR. IYABO O OTEKUNRIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	102X00000X	Poetry Therapist
2	133N00000X	Nutritionist
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1437634417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IYABO O OTEKUNRIN MD

Provider Business Mailing Address
First Line	:	1410 WILLOW LAKE DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2804
Country	:	US
Telephone Number	:	678-886-9651
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 BRIARCLIFF RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-2618
Country	:	US
Telephone Number	:	404-698-4281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2018
Last Update Date	:	09/26/2018

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