Healthcare Provider Details

I. General information

NPI: 1902200835
Provider Name (Legal Business Name): ODIANOSEN IDIAHI OBADAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 PROFESSIONAL DR STE 235A
LAWRENCEVILLE GA
30046-7697
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 470-292-3957
  • Fax: 470-292-3683
Mailing address:
  • Phone: 815-741-6830
  • Fax: 815-741-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD61234746
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number84734
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61234746
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number86371
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: