Provider Demographics
NPI:1134689771
Name:SOBUKONLA, TIMOTHY IMOLEAYO (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:IMOLEAYO
Last Name:SOBUKONLA
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 1:1194 REALM LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2679
Mailing Address - Country:US
Mailing Address - Phone:580-695-5114
Mailing Address - Fax:
Practice Address - Street 1:720 WESTVIEW DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1458
Practice Address - Country:US
Practice Address - Phone:404-756-1368
Practice Address - Fax:404-756-1313
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine