Healthcare Provider Details

I. General information

NPI: 1669730552
Provider Name (Legal Business Name): MOFOLASADE ADEYI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FOLASADE OLOWUDE M.D.

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 SIXES RD
CANTON GA
30114-9102
US

IV. Provider business mailing address

3333 RIVERWOOD PKWY SE STE 250
ATLANTA GA
30339-3304
US

V. Phone/Fax

Practice location:
  • Phone: 678-374-7514
  • Fax: 770-914-1070
Mailing address:
  • Phone: 770-914-0116
  • Fax: 770-955-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101260600
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number79925
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: