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General NPI Number Information
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NPI Number | 1396929444
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Entity Type | Organization
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Legal Business Name | TOTAL GRACE PEDIATRICS P.C.
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 12/26/2007
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Provider Practice Location Address
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Address Line | 900 N HAIRSTON RD # RS SUITE A
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-2857
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Country | US
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Telephone | 404-292-8103
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Fax | 404-292-8105
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Provider Business Mailing Address
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Address Line | 900 N HAIRSTON RD # RS SUITE A
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-2857
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Country | US
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Telephone | 404-292-8103
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Fax | 404-292-8105
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. BASHIRU A DAWODU
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Credential | M.D.
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Telephone | 404-292-8103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 052162
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License Number State | GA
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