Healthcare Provider Details

I. General information

NPI: 1023312832
Provider Name (Legal Business Name): ERNESTINE NONYE JIDEAMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2011
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SE 5TH AVE
DELRAY BEACH FL
33483-5206
US

IV. Provider business mailing address

236 ARROWHEAD BLVD
JONESBORO GA
30236-1106
US

V. Phone/Fax

Practice location:
  • Phone: 561-272-8991
  • Fax:
Mailing address:
  • Phone: 770-478-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number550256
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME131259
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: