MEDICARE: DR. THEODORA MBANEFO MD

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	207R00000X	Internal Medicine Physician	056596	GA

General Provider Information

NPI Number	:	1376611764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORA MBANEFO MD

Provider Business Mailing Address
First Line	:	3495 PIEDMONT RD NE
Second Line	:	NINE PIEDMONT CENTER
City	:	ATLANTA
State	:	GA
Zip	:	30305-1773
Country	:	US
Telephone Number	:	404-364-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 STEVE REYNOLDS BLVD
Second Line	:	DEPARTMENT OF INTERNAL MEDICINE
City	:	DULUTH
State	:	GA
Zip	:	30096-4506
Country	:	US
Telephone Number	:	770-931-6065
Fax Number	:

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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