Provider Demographics
NPI:1194915470
Name:OGUNDIPE, OLUSHESAN MARTINS (MD)
Entity type:Individual
Prefix:
First Name:OLUSHESAN MARTINS
Middle Name:
Last Name:OGUNDIPE
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 1:2727 PACES FERRY RD SE STE 1-1100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6151
Mailing Address - Country:US
Mailing Address - Phone:470-271-3420
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-5076
Practice Address - Fax:260-373-6348
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059840207R00000X, 208M00000X
IN01069915A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200922610Medicaid
IN000000724341OtherANTHEM
IN200922610Medicaid