Provider Demographics
NPI:1659391456
Name:OVBIAGELE, FORTUNATE EHI (M D)
Entity Type:Individual
Prefix:
First Name:FORTUNATE
Middle Name:EHI
Last Name:OVBIAGELE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100242
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0242
Mailing Address - Country:US
Mailing Address - Phone:334-383-2247
Mailing Address - Fax:334-383-2342
Practice Address - Street 1:29 L V STABLER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-3850
Practice Address - Country:US
Practice Address - Phone:334-383-2249
Practice Address - Fax:334-383-2342
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000222412084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051098107OtherBCBS INPATIENT
AL051550185Medicaid
AL051098108OtherBCBS OUTPATIENT
AL260050017OtherRAILROAD MEDICARE
AL009942355Medicaid
AL009942355Medicaid
AL051550185Medicaid
AL051550185Medicare PIN