Provider Demographics
NPI:1255584355
Name:OPANUGA, ADEMOLA ADEBAYO (MD)
Entity type:Individual
Prefix:DR
First Name:ADEMOLA
Middle Name:ADEBAYO
Last Name:OPANUGA
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:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:404-365-0160
Mailing Address - Fax:770-903-0169
Practice Address - Street 1:6330 PRIMROSE HILL CT
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4544
Practice Address - Country:US
Practice Address - Phone:404-365-0160
Practice Address - Fax:770-903-0169
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0066352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113063GMedicaid
GA1609816123OtherGEORGIA CLINIC, PC GROUP NPI #
GA003113063GMedicaid