Provider Demographics
NPI:1578623443
Name:OSOBA, OLUGBEMIGA A (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUGBEMIGA
Middle Name:A
Last Name:OSOBA
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 1:4780 ASHFORD DUNWOODY RD STE 621A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5564
Mailing Address - Country:US
Mailing Address - Phone:404-953-5348
Mailing Address - Fax:888-862-6985
Practice Address - Street 1:4028 HOLCOMB BRIDGE RD STE 204
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-4600
Practice Address - Country:US
Practice Address - Phone:404-953-5348
Practice Address - Fax:888-862-6985
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM95612084P0804X
NJ25MA116056002084P0804X
GA593002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OO074832OtherCHAMPUS-CHAMPUS
7509104450OtherBLUE CROSS-BLUE CROSS
GA974647115FMedicaid
OO074832OtherCOMMERCIAL-COMMERCIAL NUMBER
OO074832OtherCHAMPUS-CHAMPUS
0H26229095Medicare ID - Type Unspecified
MI462078410Medicaid