Healthcare Provider Details

I. General information

NPI: 1891115465
Provider Name (Legal Business Name): JUNE TIBALEKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 HIGHWAY 34 E STE 1200
NEWNAN GA
30265-6416
US

IV. Provider business mailing address

3375 SPRING HILL PKWY SE APT 318
SMYRNA GA
30080-6805
US

V. Phone/Fax

Practice location:
  • Phone: 770-502-2112
  • Fax: 770-502-2113
Mailing address:
  • Phone: 443-939-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2017-0609
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number86579
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: