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: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MEDICAL PAVILION DR
RAEFORD NC
28376-9111
US

IV. Provider business mailing address

3651 WHEELER RD
AUGUSTA GA
30909-6426
US

V. Phone/Fax

Practice location:
  • Phone: 910-904-8000
  • Fax:
Mailing address:
  • Phone: 706-651-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD61234746
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number86371
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number84734
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024-00310
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61234746
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: