Healthcare Provider Details

I. General information

NPI: 1073200424
Provider Name (Legal Business Name): THEODORA CHIEMEKA ESOMONYE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GME 720 WESTVIEW DR, SW
ATLANTA GA
30310
US

IV. Provider business mailing address

GME 720 WESTVIEW DR, SW
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 404-756-1383
  • Fax: 404-756-1313
Mailing address:
  • Phone: 404-756-1383
  • Fax: 404-756-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: