Provider Demographics
NPI:1538138326
Name:ADEDUNTAN, AZEEZ POPOOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:AZEEZ
Middle Name:POPOOLA
Last Name:ADEDUNTAN
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 1:435 HAWTHORNE AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2574
Mailing Address - Country:US
Mailing Address - Phone:706-227-0871
Mailing Address - Fax:706-227-0865
Practice Address - Street 1:435 HAWTHORNE AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2574
Practice Address - Country:US
Practice Address - Phone:706-227-0871
Practice Address - Fax:706-227-0865
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040293174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00670381CMedicaid
GA00670381CMedicaid
GAF61706Medicare UPIN