Healthcare Provider Details

I. General information

NPI: 1952496770
Provider Name (Legal Business Name): NKIRUKA J UDEJIOFOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NKIRUKA J ONWUBIKO

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 TOWN PARK LANE KAISER PERMANENLE TOWN PARK COMPREHENSIVE MEDICAL CENTE
KENNESAW GA
30144
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-5401
  • Fax:
Mailing address:
  • Phone: 404-504-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061199A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number059340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: