Provider Demographics
NPI:1043689623
Name:WANZU, KIBIBI
Entity Type:Individual
Prefix:
First Name:KIBIBI
Middle Name:
Last Name:WANZU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 BEAR CREEK BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1864
Mailing Address - Country:US
Mailing Address - Phone:470-781-5585
Mailing Address - Fax:470-781-5586
Practice Address - Street 1:990 BEAR CREEK BLVD STE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:470-781-5585
Practice Address - Fax:470-781-5586
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001378213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003207314Medicaid
GA003207314GMedicaid
GA14312441OtherCAQH