Provider Demographics
NPI:1063483550
Name:COKER, ERNEST EBUN (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:EBUN
Last Name:COKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601A PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:770-822-4120
Mailing Address - Fax:770-822-2830
Practice Address - Street 1:601A PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 180
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-822-4120
Practice Address - Fax:770-822-2830
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52727251OtherBLUE CROSS BLUE SHIELD
GA000740671DMedicaid
GA52727251OtherBLUE CROSS BLUE SHIELD