Healthcare Provider Details

I. General information

NPI: 1346731635
Provider Name (Legal Business Name): SAMSON ADEWALE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 01/21/2026
Certification Date: 01/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 LAWRENCEVILLE SUWANEE RD STE 100
SUWANEE GA
30024-2612
US

IV. Provider business mailing address

257 LAWRENCE ST NE UNIT 571
MARIETTA GA
30061-2309
US

V. Phone/Fax

Practice location:
  • Phone: 404-644-3747
  • Fax:
Mailing address:
  • Phone: 404-644-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number92679
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number33902
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.43245
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.43245
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33902
License Number StateOK
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92679
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: