Healthcare Provider Details

I. General information

NPI: 1386149425
Provider Name (Legal Business Name): VINCE IFEANYI CHUKWUKELU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 08/09/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7813 SPIVEY STATION BLVD STE 220
JONESBORO GA
30236-2900
US

IV. Provider business mailing address

7813 SPIVEY STATION BLVD STE 220
JONESBORO GA
30236-2900
US

V. Phone/Fax

Practice location:
  • Phone: 404-251-2328
  • Fax: 404-251-2316
Mailing address:
  • Phone: 404-251-2328
  • Fax: 404-251-2316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number90086
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number010544
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: