Healthcare Provider Details

I. General information

NPI: 1831777036
Provider Name (Legal Business Name): VIVIEN MOKUU EDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 678-427-2953
  • Fax:
Mailing address:
  • Phone: 770-219-8721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number98962
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: