Provider Demographics
NPI:1548313851
Name:SOBANJO, ELIZABETH IMADE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:IMADE
Last Name:SOBANJO
Suffix:
Gender:F
Credentials:OD
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Other - First Name:
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Mailing Address - Street 1:1525 E PARK PLACE BLVD
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3453
Mailing Address - Country:US
Mailing Address - Phone:770-498-3434
Mailing Address - Fax:770-498-3440
Practice Address - Street 1:1525 E PARK PLACE BLVD
Practice Address - Street 2:SUITE 1800
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3453
Practice Address - Country:US
Practice Address - Phone:770-498-3434
Practice Address - Fax:770-498-3440
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1538152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000900413AMedicaid
GAU81118Medicare UPIN