Provider Demographics
NPI:1437634417
Name:OTEKUNRIN, IYABO O (MD)
Entity Type:Individual
Prefix:DR
First Name:IYABO
Middle Name:O
Last Name:OTEKUNRIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 WILLOW LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2804
Mailing Address - Country:US
Mailing Address - Phone:678-886-9651
Mailing Address - Fax:
Practice Address - Street 1:1000 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-2618
Practice Address - Country:US
Practice Address - Phone:404-698-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty