Ojoru Osunkoya, MD
Individual provider Active NPI Pediatrics Physician · Clarkston, GA
NPI 1679528491 · NPPES record last updated Sep 11, 2012
Key facts
- NPI
- 1679528491
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- 059578 (GA)
- Practice address
- 4112 E. Ponce de Leon
Clarkston, GA 30021 - Phone
- (404) 296-7133
- NPI assigned
- May 23, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080211000196 | GA | Practitioner - Pediatric Medicine | 4789687781 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 059578 | GA | MD | Pediatrics Physician |
| 23461 | OK | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| The Southeast Permanente Medical Group | Pediatrics | Current |
Accepting new patients |
Locations
3495 Piedmont Rd NE
Bldg 9
Atlanta, GA 30305
Phone (404) 364-7000
2240 Fountain Dr
Snellville, GA 30078
Phone (404) 379-1105
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 23461 | OK | |
| Pediatrics Physician | 208000000X | 059578 | GA | Yes |
Addresses
Primary practice location
4112 E. Ponce de Leon
Clarkston, GA 30021
Mailing address
4112 E. Ponce de Leon
Clarkston, GA 30021
Phone (404) 296-7133
Other names
- Nee Idachaba
Other providers in Clarkston, GA
- Yolanda Nesbitt
- Trung The Nguyen
- Dana Vermelle Nowlin
- Nurture Home Care LLC
- Kareem Osborne
- Sydney Otuata
- PCL Labs LLC
- Peach Dental Care
- Vanessa Phan
- Pharm R X Inc
All providers in Clarkston, GA · Pediatrics Physician in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 11, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.