Healthcare Provider Details

I. General information

NPI: 1497771034
Provider Name (Legal Business Name): EMMANUEL O SOYOOLA M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/05/2012
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 TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number053032
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53032
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number53032
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: