Healthcare Provider Details

I. General information

NPI: 1245521905
Provider Name (Legal Business Name): OLUSOLA OBAYOMI-DAVIES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 KENNESTONE HOSPITAL BLVD STE LL1
MARIETTA GA
30060
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7500
  • Fax: 770-793-7985
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD457543
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number84047
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: