Healthcare Provider Details

I. General information

NPI: 1477647410
Provider Name (Legal Business Name): ANTHONY C ONYEGBULA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 UPPER RIVERDALE RD SW STE 3-4
RIVERDALE GA
30274-2529
US

IV. Provider business mailing address

PO BOX 1710
STOCKBRIDGE GA
30281-8710
US

V. Phone/Fax

Practice location:
  • Phone: 770-629-2337
  • Fax: 888-651-5324
Mailing address:
  • Phone: 770-629-2337
  • Fax: 888-651-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53348
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number053348
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number53348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: