Provider Demographics
NPI:1083706055
Name:OGUNTUNMIBI, ADEWUMI OLUSEGUN (MD)
Entity Type:Individual
Prefix:
First Name:ADEWUMI
Middle Name:OLUSEGUN
Last Name:OGUNTUNMIBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5968
Mailing Address - Country:US
Mailing Address - Phone:912-354-7679
Mailing Address - Fax:912-354-4018
Practice Address - Street 1:411 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5968
Practice Address - Country:US
Practice Address - Phone:912-354-7679
Practice Address - Fax:912-354-4018
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049393174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00900798GMedicaid
GA00900798DMedicaid
GA00900798EMedicaid
GA00900798HMedicaid
GAN365366OtherWELLCARE OF GEORGIA
GA000900798MMedicaid
GA930105831OtherRAILROAD MEDICARE
GA00900798FMedicaid
GA00900798CMedicaid
SCG49393Medicaid
GA000900798IMedicaid
GA00900798CMedicaid
GA000900798IMedicaid