Healthcare Provider Details

I. General information

NPI: 1255584355
Provider Name (Legal Business Name): ADEMOLA ADEBAYO OPANUGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 PRIMROSE HILL CT
NORCROSS GA
30092-4544
US

IV. Provider business mailing address

PO BOX 769609
ROSWELL GA
30076-8224
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0160
  • Fax: 770-903-0169
Mailing address:
  • Phone: 404-365-0160
  • Fax: 770-903-0169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0066352
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: