Provider Demographics
NPI:1871617274
Name:ORIMOGUNJE, YETUNDE O (MD)
Entity type:Individual
Prefix:
First Name:YETUNDE
Middle Name:O
Last Name:ORIMOGUNJE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-0000
Practice Address - Country:US
Practice Address - Phone:770-277-3056
Practice Address - Fax:855-204-5244
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC92878207L00000X
GA059576207L00000X
NY240933207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA227142336CMedicaid
GA227142336AMedicaid
GA415429OtherWELLCARE
GA52231382001OtherBCBS OF GA
GA227142336BMedicaid
P00457334OtherRAILROAD MEDICARE
GA52231382001OtherBCBS OF GA