Provider Demographics
NPI:1033472261
Name:OBI, JENNIFER IFEOMA (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:IFEOMA
Last Name:OBI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 MOONHAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4954
Mailing Address - Country:US
Mailing Address - Phone:571-282-7960
Mailing Address - Fax:
Practice Address - Street 1:1800 TREE LN STE 200
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2060
Practice Address - Country:US
Practice Address - Phone:770-979-0367
Practice Address - Fax:770-979-1830
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA84046207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty