Basic Information
| Provider Information | |||||||||
| NPI: | 1144809443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GADJIKO | ||||||||
| FirstName: | MARIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 162 FOXGLOVE CIR | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290638274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033510017 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2021 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | VA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.