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General NPI Number Information
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NPI Number | 1154811958
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Entity Type | Individual
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Provider Name | IDORENYIN EKA-IMO NDEM MD
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Gender | Female
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 07/08/2024
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Provider Practice Location Address
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Address Line | 1001 JOHNSON FERRY RD
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City | ATLANTA
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State | GA
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Zip | 30342-1605
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Country | US
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Telephone | 404-785-7792
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Fax |
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Provider Business Mailing Address
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Address Line | 975 JOHNSON FERRY RD STE 100
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City | ATLANTA
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State | GA
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Zip | 30342-1618
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Country | US
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Telephone | 404-785-7792
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Fax | 919-966-3814
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 238506
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | 100641
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License Number State | GA
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