Healthcare Provider Details

I. General information

NPI: 1649296039
Provider Name (Legal Business Name): OLUWAYEMISI IBRAHEEM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

THE EMORY CLINIC INC 1365 CLIFTON RD.
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

4850 OUTLOOK RD
ELLENWOOD GA
30294-6596
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-1868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number53759
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number53759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: