Healthcare Provider Details

I. General information

NPI: 1942554936
Provider Name (Legal Business Name): EZIAMAKA OBUNADIKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 HAWKS LN NE
BROOKHAVEN GA
30329-2283
US

IV. Provider business mailing address

11655 FOREST LAKE DR
ROLLA MO
65401-7304
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7142
  • Fax:
Mailing address:
  • Phone: 773-853-8141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number081022
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: