Provider Demographics
NPI:1649270158
Name:OLOGUNJA, KOLA
Entity type:Individual
Prefix:DR
First Name:KOLA
Middle Name:
Last Name:OLOGUNJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 CREEKSIDE VILLAGE DR NW
Mailing Address - Street 2:SUITE 504
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3104 CREEKSIDE VILLAGE DR NW
Practice Address - Street 2:SUITE 504
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2358
Practice Address - Country:US
Practice Address - Phone:770-966-0778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050548208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000972408GMedicaid
GA855356OtherBLUE CROSS BLUE SHIELD
GA855356OtherBLUE CROSS BLUE SHIELD