Healthcare Provider Details

I. General information

NPI: 1659391456
Provider Name (Legal Business Name): FORTUNATE EHI OVBIAGELE M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 L V STABLER DR
GREENVILLE AL
36037-3850
US

IV. Provider business mailing address

PO BOX 100242
ATLANTA GA
30384-0242
US

V. Phone/Fax

Practice location:
  • Phone: 334-383-2249
  • Fax: 334-383-2342
Mailing address:
  • Phone: 334-383-2247
  • Fax: 334-383-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number00022241
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number00022241
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: