Healthcare Provider Details

I. General information

NPI: 1942300769
Provider Name (Legal Business Name): OLUFEMI A OGUNYEMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FIELDSTONE DR SUITE 104
MILLEDGEVILLE GA
31061-7106
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 478-414-9900
  • Fax: 706-286-7089
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number045566
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number045566
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: