Healthcare Provider Details

I. General information

NPI: 1588270391
Provider Name (Legal Business Name): BUZZY C OGUIKE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 IRVIN CT STE 110
DECATUR GA
30030-5406
US

IV. Provider business mailing address

2041 MESA VALLEY WAY STE 100
AUSTELL GA
30106-6856
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3642
  • Fax: 770-962-3643
Mailing address:
  • Phone: 770-944-1100
  • Fax: 770-944-6469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10029
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: