Healthcare Provider Details

I. General information

NPI: 1215925078
Provider Name (Legal Business Name): ADEKUNLE EMMANUEL OLUWADARE OD MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1342 AUBURN RD
DACULA GA
30019-1674
US

IV. Provider business mailing address

3592 HUDDLESTONE LN
BUFORD GA
30519-4652
US

V. Phone/Fax

Practice location:
  • Phone: 770-237-8150
  • Fax: 678-889-9546
Mailing address:
  • Phone: 610-800-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG001715
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberGA2345
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: