=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104918556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IGHOVWERHA OFOTOKUN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 341 PONCE DE LEON AVENUE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-616-0659
-----------------------------------------------------
Fax | 404-616-0592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | EMORY UNIVERSITY SCHOOL OF MEDICINE, DEPT. OF MEDICINE DIVISION OF INFECTIOUS DISEASES, 69 JESSE HILL JR. DR.
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-616-0659
-----------------------------------------------------
Fax | 404-616-0592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 053346
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------