Basic Information
| Provider Information | |||||||||
| NPI: | 1629133103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OKUNDAYE | ||||||||
| FirstName: | OSAGIE | ||||||||
| MiddleName: | OSARUME | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Practice Location | |||||||||
| Address1: | 4550 COBB PARKWAY NORTH NW | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301014180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709748479 | ||||||||
| FaxNumber: | 7709748710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 055488 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 749760085F | 05 | GA | MEDICAID | 749760085G | 05 | GA | MEDICAID |