Provider Demographics
NPI:1497324131
Name:OLATUNJI, GRACE OLUWASEYI (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:OLUWASEYI
Last Name:OLATUNJI
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 1:1199 PRINCE AVE # 70
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 HAWTHORNE PARK
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2147
Practice Address - Country:US
Practice Address - Phone:706-353-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-09-12
Deactivation Date:2022-12-05
Deactivation Code:
Reactivation Date:2022-12-28
Provider Licenses
StateLicense IDTaxonomies
GA100157207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine