Healthcare Provider Details

I. General information

NPI: 1124334628
Provider Name (Legal Business Name): TAIWO OLUSHOLA ODEDEYI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 ARROWHEAD BLVD
JONESBORO GA
30236-1102
US

IV. Provider business mailing address

222 ARROWHEAD BLVD
JONESBORO GA
30236-1102
US

V. Phone/Fax

Practice location:
  • Phone: 678-610-7100
  • Fax: 678-610-7111
Mailing address:
  • Phone: 678-610-7100
  • Fax: 678-610-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number64622
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: