Provider Demographics
NPI:1083238448
Name:ANDRE, TINUOLA OMONIYI (MD)
Entity Type:Individual
Prefix:MS
First Name:TINUOLA
Middle Name:OMONIYI
Last Name:ANDRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:TINUOLA
Other - Middle Name:OMONIYI
Other - Last Name:FAKOYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1199 PRINCE AVE
Mailing Address - Street 2:#70
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 PRINCE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2023-06-28
Deactivation Date:2022-01-18
Deactivation Code:
Reactivation Date:2022-02-02
Provider Licenses
StateLicense IDTaxonomies
GA95863208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice