Provider Demographics
NPI:1215925078
Name:OLUWADARE, ADEKUNLE EMMANUEL (OD MSC)
Entity type:Individual
Prefix:
First Name:ADEKUNLE
Middle Name:EMMANUEL
Last Name:OLUWADARE
Suffix:
Gender:
Credentials:OD MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3592 HUDDLESTONE LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4652
Mailing Address - Country:US
Mailing Address - Phone:610-800-1125
Mailing Address - Fax:
Practice Address - Street 1:1342 AUBURN RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1674
Practice Address - Country:US
Practice Address - Phone:770-237-8150
Practice Address - Fax:678-889-9546
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001715152W00000X
GAGA2345152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA2345OtherLICENSE TO PRACTICE OPTOMETRY