Healthcare Provider Details

I. General information

NPI: 1043630627
Provider Name (Legal Business Name): JOSEPH OBUBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-7796
  • Fax: 404-294-3710
Mailing address:
  • Phone: 404-294-3836
  • Fax: 404-508-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN228348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: