Provider Demographics
NPI:1922280684
Name:MOBOLAJI SHALOM OYEBANJO, INC
Entity Type:Organization
Organization Name:MOBOLAJI SHALOM OYEBANJO, INC
Other - Org Name:THE POTTER BEHAVIORAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MOBOLAJI
Authorized Official - Middle Name:
Authorized Official - Last Name:OYEBANJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-459-8799
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA327161185AMedicaid
GA327161185BMedicaid
GA327161185BMedicaid
GA511G700335Medicare PIN