Provider Demographics
NPI:1851424378
Name:VICTORY VASCULAR & GENERAL SURGERY OF GEORGIA PC
Entity Type:Organization
Organization Name:VICTORY VASCULAR & GENERAL SURGERY OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZEEZ
Authorized Official - Middle Name:POPOOLA
Authorized Official - Last Name:ADEDUNTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-227-0871
Mailing Address - Street 1:435 HAWTHORNE AVE
Mailing Address - Street 2:#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:#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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0402932086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000670381CMedicaid
GA02BDDXSMedicare PIN
GAF61706Medicare UPIN