=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265758502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OGHENERUKEVWE ODIETE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2010
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1825 HIGHWAY 34 E STE 3400
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265-6433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-400-9588
-----------------------------------------------------
Fax | 470-400-3452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 LAKE HEARN DR STE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-400-9588
-----------------------------------------------------
Fax | 470-400-3452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | 78089
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------