Healthcare Provider Details

I. General information

NPI: 1740328160
Provider Name (Legal Business Name): MR. DAVID ADETUNJI FATADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

4229 RIDGESIDE TER
SNELLVILLE GA
30039-6831
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-728-4708
Mailing address:
  • Phone: 770-972-5730
  • Fax: 770-972-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN163665
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: