Healthcare Provider Details

I. General information

NPI: 1336374313
Provider Name (Legal Business Name): EMMANUEL O SOYOOLA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2169 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-7710
US

IV. Provider business mailing address

2169 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-7710
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3700
  • Fax: 770-962-8063
Mailing address:
  • Phone: 770-962-3700
  • Fax: 770-962-8063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53032
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number53032
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number53032
License Number StateGA

VIII. Authorized Official

Name: DR. EMMANUEL SOYOOLA
Title or Position: PHYSICIAN/OWNER
Credential: M.D,PHD.,F.A.C.O.G.
Phone: 770-962-3700