Provider Demographics
NPI:1518965938
Name:TENIOLA, SAMUEL O (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:O
Last Name:TENIOLA
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 1:945 LINSLEY WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6083
Mailing Address - Country:US
Mailing Address - Phone:770-879-9659
Mailing Address - Fax:
Practice Address - Street 1:285 BOULEVARD NE
Practice Address - Street 2:SUITE 435
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4205
Practice Address - Country:US
Practice Address - Phone:404-524-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000891514BMedicaid
GA000891514BMedicaid
GA11BDSVTMedicare ID - Type Unspecified