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General NPI Number Information
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NPI Number | 1225567225
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Entity Type | Organization
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Legal Business Name | WATERFALLS MEDICAL PRACTICE, P.C
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Dates
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Enumeration Date | 06/05/2017
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Last Update Date | 06/16/2020
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Provider Practice Location Address
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Address Line | 112 GOVERNORS SQ STE B
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-4864
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Country | US
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Telephone | 678-932-8112
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Fax | 678-932-8113
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Provider Business Mailing Address
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Address Line | 1202 TOLMOUNT CT
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-3348
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Country | US
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Telephone | 678-932-8112
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Fax | 678-932-8113
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. IRENE AYOYINKA OMOTOSO
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Credential | MD
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Telephone | 678-932-8112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 053629
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License Number State | GA
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