Provider Demographics
NPI:1902200835
Name:OBADAN, ODIANOSEN I (MD)
Entity Type:Individual
Prefix:
First Name:ODIANOSEN
Middle Name:I
Last Name:OBADAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3877
Mailing Address - Country:US
Mailing Address - Phone:815-741-6830
Mailing Address - Fax:815-741-6832
Practice Address - Street 1:601 PROFESSIONAL DR STE 235A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7697
Practice Address - Country:US
Practice Address - Phone:470-292-3957
Practice Address - Fax:470-292-3683
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84734207R00000X
WAMD61234746207RN0300X
GA86371207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC847347Medicaid