Healthcare Provider Details

I. General information

NPI: 1063806982
Provider Name (Legal Business Name): KEHINDE OPEOLUWA IDOWU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2015
Last Update Date: 03/07/2023
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8954 HOSPITAL DR
DOUGLASVILLE GA
30134-2272
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE UNIT 9A
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-2585
  • Fax: 678-838-2587
Mailing address:
  • Phone: 404-274-9386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number80489
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: