MEDICARE: RALPH OGWOTU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	233148	GA
2	163W00000X	Registered Nurse	RN233148	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144674581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RALPH OGWOTU

Provider Business Mailing Address
First Line	:	110 W PIER WAY
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4617
Country	:	US
Telephone Number	:	404-514-3498
Fax Number	:

Provider Business Practice Location Address
First Line	:	6572 RIVER PARK DR STE 101
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2214
Country	:	US
Telephone Number	:	404-514-3498
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2016
Last Update Date	:	07/22/2024

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Directions to “ RALPH OGWOTU ” Practice Location

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