Healthcare Provider Details

I. General information

NPI: 1740474154
Provider Name (Legal Business Name): OSARETIN DANIEL OKUNGBOWA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 LESTER RD
STATESBORO GA
30458-4700
US

IV. Provider business mailing address

23 LESTER RD
STATESBORO GA
30458-4700
US

V. Phone/Fax

Practice location:
  • Phone: 912-225-1836
  • Fax: 912-225-0645
Mailing address:
  • Phone: 912-225-1836
  • Fax: 912-225-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2009-0144
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62926
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: