Provider Demographics
NPI:1952301830
Name:ODUWOLE, ADEFISAYO (MD)
Entity Type:Individual
Prefix:
First Name:ADEFISAYO
Middle Name:
Last Name:ODUWOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 HIGHWAY 85 N STE 310-296
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:678-571-2956
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:STE 2E
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-616-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042381207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000728407UMedicaid
GA000728417CMedicaid
GA000728407CMedicaid
GA000728407CMedicaid
GA06BDFJPMedicare PIN