Healthcare Provider Details

I. General information

NPI: 1336121946
Provider Name (Legal Business Name): ADEBOWALE OGUNSEYE OGUNTOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 LANIER PARK DR
GAINESVILLE GA
30501-2059
US

IV. Provider business mailing address

663 LANIER PARK DR
GAINESVILLE GA
30501-2059
US

V. Phone/Fax

Practice location:
  • Phone: 678-450-0202
  • Fax: 678-450-0080
Mailing address:
  • Phone: 678-450-0202
  • Fax: 678-450-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number212959
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number97988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: