Healthcare Provider Details

I. General information

NPI: 1912544784
Provider Name (Legal Business Name): MALOZERA PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2019
Last Update Date: 11/18/2023
Certification Date: 11/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 PINE ST
UNADILLA GA
31091-7701
US

IV. Provider business mailing address

P O BOX 8203
WARNER ROBINS GA
31095-8203
US

V. Phone/Fax

Practice location:
  • Phone: 478-355-3000
  • Fax: 478-355-3001
Mailing address:
  • Phone: 478-783-3610
  • Fax: 478-783-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEXANDER C IBEZI-ENENDU
Title or Position: OWNER
Credential: DO
Phone: 404-702-9466