MEDICARE: DR. DANIELLE IBELEMA M.D

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	2080A0000X	Pediatric Adolescent Medicine Physician	076263	GA
2	2084P0800X	Psychiatry Physician	76263	GA
3	2084P0804X	Child & Adolescent Psychiatry Physician	76263	GA
4	208000000X	Pediatrics Physician	76263	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	076263	OTHER	GA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1326331042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIELLE IBELEMA M.D

Provider Business Mailing Address
First Line	:	4062 PEACHTREE RD NE STE A-536
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3021
Country	:	US
Telephone Number	:	678-827-5797
Fax Number	:

Provider Business Practice Location Address
First Line	:	4062 PEACHTREE RD NE STE A-536
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-3021
Country	:	US
Telephone Number	:	678-322-8138
Fax Number	:

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

Provider Enumeration Date	:	05/27/2011
Last Update Date	:	01/13/2021

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