Provider Demographics
NPI:1407114739
Name:BOLA SOGADE, MD, LLC
Entity Type:Organization
Organization Name:BOLA SOGADE, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOGADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-745-3014
Mailing Address - Street 1:639 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6886
Mailing Address - Country:US
Mailing Address - Phone:478-745-3014
Mailing Address - Fax:
Practice Address - Street 1:639 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6886
Practice Address - Country:US
Practice Address - Phone:478-745-3014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty