Provider Demographics
NPI:1306803762
Name:ODUSINA, BOLAJI T (MD)
Entity type:Individual
Prefix:
First Name:BOLAJI
Middle Name:T
Last Name:ODUSINA
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 1:1155 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5425
Mailing Address - Country:US
Mailing Address - Phone:678-442-0205
Mailing Address - Fax:678-442-0185
Practice Address - Street 1:1155 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5425
Practice Address - Country:US
Practice Address - Phone:678-442-0205
Practice Address - Fax:678-442-0185
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042380208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F86425Medicare UPIN