Provider Demographics
NPI:1053314823
Name:FALASE, EKUNDAYO ADEDAPO (MD)
Entity Type:Individual
Prefix:DR
First Name:EKUNDAYO
Middle Name:ADEDAPO
Last Name:FALASE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1157
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1612 MILSTEAD RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3738
Practice Address - Country:US
Practice Address - Phone:678-413-3261
Practice Address - Fax:678-413-3580
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044714207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000924536BMedicaid
GAG60203Medicare UPIN
GA39BDCDJMedicare ID - Type Unspecified