Healthcare Provider Details

I. General information

NPI: 1427344175
Provider Name (Legal Business Name): SOPE OMOWALE OLUGBILE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 HOWELL MILL RD NW STE 300
ATLANTA GA
30318-0918
US

IV. Provider business mailing address

85 RETREAT STREET HARTFORD HOSPITAL CANCER CENTER
HARTFORD CT
06106-2555
US

V. Phone/Fax

Practice location:
  • Phone: 404-425-1777
  • Fax:
Mailing address:
  • Phone: 860-249-6291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number064042
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number064042
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number35.130693
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number064042
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number101581
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: