Provider Demographics
NPI:1467581009
Name:OLADAYO OSINUGA MD PC
Entity Type:Organization
Organization Name:OLADAYO OSINUGA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLADAYO
Authorized Official - Middle Name:A
Authorized Official - Last Name:OSINUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-474-5470
Mailing Address - Street 1:4348 KLONDIKE ROAD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4417
Mailing Address - Country:US
Mailing Address - Phone:770-474-5470
Mailing Address - Fax:770-474-4620
Practice Address - Street 1:4348 KLONDIKE ROAD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-4417
Practice Address - Country:US
Practice Address - Phone:770-474-5470
Practice Address - Fax:770-474-4620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00194327OtherMEDICARE RAILROAD
GAP00194327OtherMEDICARE RAILROAD
GA11SCCXSMedicare ID - Type Unspecified
GAGRP6579Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER