Provider Demographics
NPI:1578754503
Name:OYEBANJO POPOOLA, OMOBOLAJI OLUSEYI (MD)
Entity Type:Individual
Prefix:
First Name:OMOBOLAJI
Middle Name:OLUSEYI
Last Name:OYEBANJO POPOOLA
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 1:307 OLD STONE RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1214
Mailing Address - Country:US
Mailing Address - Phone:770-459-8799
Mailing Address - Fax:770-459-8919
Practice Address - Street 1:307 OLD STONE RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1214
Practice Address - Country:US
Practice Address - Phone:770-459-8799
Practice Address - Fax:770-459-8919
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6125672084A0401X
GA0535092084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDKGPMedicare PIN