Provider Demographics
NPI:1235343088
Name:OMOLARA KUTEYI MD, INC
Entity Type:Organization
Organization Name:OMOLARA KUTEYI MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMOLARA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KUTEYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-284-7744
Mailing Address - Street 1:1262 EMMA JEAN PL SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3798
Mailing Address - Country:US
Mailing Address - Phone:404-284-7744
Mailing Address - Fax:404-284-7744
Practice Address - Street 1:3546 COVINGTON HWY
Practice Address - Street 2:SUITE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1823
Practice Address - Country:US
Practice Address - Phone:404-284-7744
Practice Address - Fax:404-284-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA053776OtherLICENSE