Provider Demographics
NPI:1861989550
Name:OMEH, DEMIAN JIDEOFOR (MD)
Entity type:Individual
Prefix:
First Name:DEMIAN
Middle Name:JIDEOFOR
Last Name:OMEH
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 1:1120 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-446-0344
Mailing Address - Fax:706-721-4180
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-446-0344
Practice Address - Fax:706-721-4180
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2025-10-24
Deactivation Date:2018-11-28
Deactivation Code:
Reactivation Date:2018-12-18
Provider Licenses
StateLicense IDTaxonomies
SC2086250207R00000X
GA105546207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program