Provider Demographics
NPI:1841285087
Name:AWE, OLUGBENGA A (MD)
Entity type:Individual
Prefix:
First Name:OLUGBENGA
Middle Name:A
Last Name:AWE
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 1:514 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4355
Mailing Address - Country:US
Mailing Address - Phone:912-448-2000
Mailing Address - Fax:912-448-2345
Practice Address - Street 1:514 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-448-2000
Practice Address - Fax:912-448-2345
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48329207R00000X
OH35073659A207R00000X
GA048329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2031607Medicaid
GA11SCGCSOtherMEDICARE PTAN
GA694476929AMedicaid
OH2031607Medicaid
GA694476929IMedicaid
OH2031607Medicaid
G67599Medicare UPIN
GA694476929AMedicaid