Provider Demographics
NPI:1497771034
Name:SOYOOLA, EMMANUEL O (MD, PHD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:O
Last Name:SOYOOLA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2169 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7710
Mailing Address - Country:US
Mailing Address - Phone:770-962-3700
Mailing Address - Fax:770-962-8063
Practice Address - Street 1:2169 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7710
Practice Address - Country:US
Practice Address - Phone:770-962-3700
Practice Address - Fax:770-962-8063
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053032207V00000X
GA53032207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1811315000Medicaid
GA413053267AMedicaid
GAH91035Medicare UPIN
WV4132711Medicare PIN
GA16BBCCPMedicare ID - Type Unspecified