=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497432538
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIKHONGI SOLOMON PHUNGWAYO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2023
-----------------------------------------------------
Last Update Date | 06/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE HB3014
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30912-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-647-9550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 922 AVOCADO ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30904-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-647-9550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 15483
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------