Provider Demographics
NPI:1861439119
Name:OSAYI, FRED OSARETIN (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:OSARETIN
Last Name:OSAYI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:FRIDAY
Other - Middle Name:OSARETIN
Other - Last Name:OSAYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7583 HIGHWAY 85
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3438
Mailing Address - Country:US
Mailing Address - Phone:770-996-3495
Mailing Address - Fax:
Practice Address - Street 1:7583 HIGHWAY 85
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3438
Practice Address - Country:US
Practice Address - Phone:770-996-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2016-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002179152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA697370621DMedicaid
41ZCFXRMedicare ID - Type Unspecified
V07335Medicare UPIN