Healthcare Provider Details

I. General information

NPI: 1417951369
Provider Name (Legal Business Name): OLATUNDE IDOWU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD BOX 22
AUSTELL GA
30106-1121
US

IV. Provider business mailing address

3950 AUSTELL RD BOX 22
AUSTELL GA
30106-1121
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-4022
  • Fax: 770-732-4023
Mailing address:
  • Phone: 770-732-4022
  • Fax: 770-732-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number057374
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number057374
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: