Provider Demographics
NPI:1083913230
Name:EGHAREVBA, OSARENOMASE (MD)
Entity Type:Individual
Prefix:
First Name:OSARENOMASE
Middle Name:
Last Name:EGHAREVBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OSA
Other - Middle Name:
Other - Last Name:EGHAREVBA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2801 DEKALB MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4996
Mailing Address - Country:US
Mailing Address - Phone:404-501-8492
Mailing Address - Fax:
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:770-918-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78620207R00000X, 208M00000X
MI4301108530208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400152646OtherMEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
IL036134788OtherMEDICAID PTAN