Healthcare Provider Details

I. General information

NPI: 1154534303
Provider Name (Legal Business Name): AKPOMUDIARE SAMUEL OTUGUOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 N CENTRAL AVE
HAPEVILLE GA
30354-1603
US

IV. Provider business mailing address

535 N CENTRAL AVE
HAPEVILLE GA
30354-1603
US

V. Phone/Fax

Practice location:
  • Phone: 404-761-4040
  • Fax: 404-761-4008
Mailing address:
  • Phone: 404-761-4040
  • Fax: 404-761-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.38189
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301086102
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65599
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number38189
License Number StateAL
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38788
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: