Healthcare Provider Details

I. General information

NPI: 1194245894
Provider Name (Legal Business Name): YUSUF ABIODUN OPAKUNLE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PROFESSIONAL DR STE 130
LAWRENCEVILLE GA
30046-7638
US

IV. Provider business mailing address

600 PROFESSIONAL DR STE 130
LAWRENCEVILLE GA
30046-7638
US

V. Phone/Fax

Practice location:
  • Phone: 770-255-0434
  • Fax: 770-255-0433
Mailing address:
  • Phone: 770-255-0434
  • Fax: 770-255-0433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number682
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001345
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: