Provider Demographics
NPI:1013194661
Name:OSINUBI, FIDELIA O (MD)
Entity Type:Individual
Prefix:
First Name:FIDELIA
Middle Name:O
Last Name:OSINUBI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:FIDELIA
Other - Middle Name:OSARUME
Other - Last Name:IDUSOGIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 20156
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30325
Mailing Address - Country:US
Mailing Address - Phone:404-349-0496
Mailing Address - Fax:404-349-6081
Practice Address - Street 1:3885 PRINCETON LAKES WAY
Practice Address - Street 2:SUITE 402
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5599
Practice Address - Country:US
Practice Address - Phone:404-349-0496
Practice Address - Fax:404-349-6081
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-25
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA778620923DMedicaid
GA06/11/1956OtherBIRTH DATE
GA778620923DMedicaid