Basic Information
| Provider Information | |||||||||
| NPI: | 1942520192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKWUMABUA | ||||||||
| FirstName: | ISIOMA | ||||||||
| MiddleName: | CHINWENDU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NWOKO | ||||||||
| OtherFirstName: | ISIOMA | ||||||||
| OtherMiddleName: | CHINWENDU | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.B.B.S | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DR SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303101458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
| FaxNumber: | 4047561402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 EAST CLEVELAND AVE | ||||||||
| Address2: | BUILDING 500 | ||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303446949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047521000 | ||||||||
| FaxNumber: | 4047521191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 070256 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003150200A | 05 | GA | MEDICAID |