1013194661 NPI number — FIDELIA O OSINUBI MD

Table of content: FIDELIA O OSINUBI MD (NPI 1013194661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013194661 NPI number — FIDELIA O OSINUBI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSINUBI
Provider First Name:
FIDELIA
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IDUSOGIE
Provider Other First Name:
FIDELIA
Provider Other Middle Name:
OSARUME
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013194661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 20156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-349-0496
Provider Business Mailing Address Fax Number:
404-349-6081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3885 PRINCETON LAKES WAY
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30331-5599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-349-0496
Provider Business Practice Location Address Fax Number:
404-349-6081
Provider Enumeration Date:
01/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  001305 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 778620923D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06/11/1956 . This is a "BIRTH DATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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