Healthcare Provider Details

I. General information

NPI: 1306886825
Provider Name (Legal Business Name): KENNETH I ATAGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 EASTMORELAND AVE STE 101
MEMPHIS TN
38104
US

IV. Provider business mailing address

1325 EASTMORELAND AVE STE 101
MEMPHIS TN
38104-3507
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-8785
  • Fax: 901-516-8358
Mailing address:
  • Phone: 901-516-8785
  • Fax: 901-516-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number9700849
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number57803
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: