Provider Demographics
NPI:1962451757
Name:OTUSESO, ENIOLA O (MD)
Entity Type:Individual
Prefix:
First Name:ENIOLA
Middle Name:O
Last Name:OTUSESO
Suffix:
Gender:F
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:PO BOX 250385
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30325-1385
Mailing Address - Country:US
Mailing Address - Phone:706-267-4999
Mailing Address - Fax:678-397-0065
Practice Address - Street 1:ANDERSON REGIONAL MEDICAL CENTER
Practice Address - Street 2:2124 14TH STREET
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301
Practice Address - Country:US
Practice Address - Phone:678-701-8267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55269207R00000X
MS18694207R00000X
AL0026308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051556231OTUMedicare ID - Type Unspecified
I19244Medicare UPIN