Healthcare Provider Details

I. General information

NPI: 1326699539
Provider Name (Legal Business Name): MR. MAGNUS OJUKWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2019
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 ROCK QUARRY RD STE 300
STOCKBRIDGE GA
30281-5024
US

IV. Provider business mailing address

1217 MCPHERSON LN APT A
NORCROSS GA
30093-4255
US

V. Phone/Fax

Practice location:
  • Phone: 678-206-2424
  • Fax:
Mailing address:
  • Phone: 501-626-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number530131
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9886
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: