Healthcare Provider Details

I. General information

NPI: 1124086020
Provider Name (Legal Business Name): MILTONIA M WOLUCHEM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MILTONIA HARVEY

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 MOUNT ZION RD
MORROW GA
30260-2357
US

IV. Provider business mailing address

1331 MOUNT ZION RD
MORROW GA
30260-2357
US

V. Phone/Fax

Practice location:
  • Phone: 770-629-3217
  • Fax: 404-666-0085
Mailing address:
  • Phone: 770-629-3217
  • Fax: 404-666-0085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number196867
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number76541
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: