Provider Demographics
NPI:1558455113
Name:SOGADE, BOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:BOLA
Middle Name:
Last Name:SOGADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BOLA
Other - Middle Name:
Other - Last Name:ADEKORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:639 HEMLOCK STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6889
Mailing Address - Country:US
Mailing Address - Phone:478-745-3014
Mailing Address - Fax:478-745-9887
Practice Address - Street 1:639 HEMLOCK STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6889
Practice Address - Country:US
Practice Address - Phone:478-745-3014
Practice Address - Fax:478-745-9887
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA836352013BMedicaid
GA322090OtherWELLCARE
GA16BBCKQMedicare ID - Type Unspecified
GA322090OtherWELLCARE