MEDICARE: VICTOR OSISANYA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	71689	GA
2	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	71689	GA
3	208VP0014X	Interventional Pain Medicine Physician	71689	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679884753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR OSISANYA M.D.

Provider Business Mailing Address
First Line	:	2550 WINDY HILL RD SE STE 215
Second Line	:	STE 215
City	:	MARIETTA
State	:	GA
Zip	:	30067-8654
Country	:	US
Telephone Number	:	770-850-8464
Fax Number	:	770-850-9727

Provider Business Practice Location Address
First Line	:	2550 WINDY HILL RD SE STE 215
Second Line	:	STE 215
City	:	MARIETTA
State	:	GA
Zip	:	30067-8654
Country	:	US
Telephone Number	:	770-850-8464
Fax Number	:	770-850-9727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2010
Last Update Date	:	02/19/2015

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Directions to “ VICTOR OSISANYA M.D.” Practice Location

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