Healthcare Provider Details

I. General information

NPI: 1801366943
Provider Name (Legal Business Name): CHELIZ OJEDA CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2018
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date: 12/02/2018
Reactivation Date: 04/10/2019

III. Provider practice location address

403 WOODCHASE WAY
WOODSTOCK GA
30188-2052
US

IV. Provider business mailing address

403 WOODCHASE WAY
WOODSTOCK GA
30188-2052
US

V. Phone/Fax

Practice location:
  • Phone: 678-956-1272
  • Fax:
Mailing address:
  • Phone: 678-956-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number5017
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5017
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: