Healthcare Provider Details

I. General information

NPI: 1558715342
Provider Name (Legal Business Name): MARIE DUFITUMUKIZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

2739 FELTON DR
EAST POINT GA
30344-3603
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1440
  • Fax: 404-778-1401
Mailing address:
  • Phone: 404-766-8371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number84074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: