Provider Demographics
NPI:1780648568
Name:KUTEYI, OMOLARA B (MD)
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:B
Last Name:KUTEYI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1262 EMMA JEAN PL SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3798
Mailing Address - Country:US
Mailing Address - Phone:404-284-7744
Mailing Address - Fax:404-284-8006
Practice Address - Street 1:3546 COVINGTON HWY
Practice Address - Street 2:STE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1823
Practice Address - Country:US
Practice Address - Phone:404-284-7744
Practice Address - Fax:404-284-8006
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2011-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA053776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA053776OtherPHYSICIAN LICENSE
GA10040207OtherAMERIGROUP
GA200819OtherBLUE CROSS BLUE SHIELD
GA774394819BOtherPEACHSTATE
GAP00183443OtherRAILROAD
GA774394819CMedicaid
GA774394819DMedicaid
GA319682OtherWELLCARE
GA774394819DMedicaid
GAP00183443OtherRAILROAD
GAI07586Medicare UPIN
GA774394819DMedicaid