Healthcare Provider Details

I. General information

NPI: 1477086536
Provider Name (Legal Business Name): GAIL OHAEGBULAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 08/25/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 SOUTHCREST DR STE 100
STOCKBRIDGE GA
30281-6119
US

IV. Provider business mailing address

770 JUNIPER ST NE
ATLANTA GA
30308-2194
US

V. Phone/Fax

Practice location:
  • Phone: 321-439-8944
  • Fax:
Mailing address:
  • Phone: 321-439-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number28604
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number100544
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: