Healthcare Provider Details

I. General information

NPI: 1275154007
Provider Name (Legal Business Name): CHRISTIANA CHIDINMA OBIOMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PONCE DE LEON AVE STE 110
DECATUR GA
30030-3467
US

IV. Provider business mailing address

200 E PONCE DE LEON AVE STE 110
DECATUR GA
30030-3467
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-6363
  • Fax: 404-377-3436
Mailing address:
  • Phone: 404-501-6363
  • Fax: 404-377-3436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number104541
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number104541
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: