Healthcare Provider Details

I. General information

NPI: 1891258083
Provider Name (Legal Business Name): ABIY LEGESSE OBOLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2019
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 PARKWAY DR NE
ATLANTA GA
30312-1212
US

IV. Provider business mailing address

303 PARKWAY DR NE
ATLANTA GA
30312-1212
US

V. Phone/Fax

Practice location:
  • Phone: 404-265-4919
  • Fax:
Mailing address:
  • Phone: 404-265-4919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number91559
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: