Provider Demographics
NPI:1174796130
Name:JOHN, OLUSEGUN SONNY (MD)
Entity type:Individual
Prefix:DR
First Name:OLUSEGUN
Middle Name:SONNY
Last Name:JOHN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 BEAVER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0240
Mailing Address - Country:US
Mailing Address - Phone:404-542-2731
Mailing Address - Fax:
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-452-0897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059982207Q00000X
MO2024016618208M00000X, 207Q00000X
VA0101245550207Q00000X
LA203985208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist