Healthcare Provider Details

I. General information

NPI: 1356385181
Provider Name (Legal Business Name): KITEFRE OKITEFRE OBOHO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVENUE SW VA FORT MCPHERSON CLINIC
ATLANTA GA
30310
US

IV. Provider business mailing address

614 SUMMERS LNDG SW
ATLANTA GA
30331-7709
US

V. Phone/Fax

Practice location:
  • Phone: 678-232-6619
  • Fax:
Mailing address:
  • Phone: 404-346-1477
  • Fax: 404-346-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number054847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: