Provider Demographics
NPI:1336374313
Name:EMMANUEL O SOYOOLA MD PC
Entity type:Organization
Organization Name:EMMANUEL O SOYOOLA MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOYOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD,FACOG
Authorized Official - Phone:770-962-3700
Mailing Address - Street 1:2169 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7710
Mailing Address - Country:US
Mailing Address - Phone:770-962-3700
Mailing Address - Fax:770-962-8063
Practice Address - Street 1:2169 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7710
Practice Address - Country:US
Practice Address - Phone:770-962-3700
Practice Address - Fax:770-962-8063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53032207Q00000X, 207V00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA413053267AMedicaid
GA413053267AMedicaid