=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649686825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAMARDEEN DIEKOLA ALABI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2014
-----------------------------------------------------
Last Update Date | 02/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2518 JIMMY LEE SMITH PKWY
-----------------------------------------------------
City | HIRAM
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30141-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-732-4022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3235 WRENWOOD CT
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-7865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-485-0234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 072672
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 072672
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------