Healthcare Provider Details

I. General information

NPI: 1396797528
Provider Name (Legal Business Name): OLADIRAN OLADAPO AMOSU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/07/2023
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

210 GRISTMILL DR
FAYETTEVILLE GA
30215-7505
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone: 770-716-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number053080
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number53080
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: