Provider Demographics
NPI:1083175533
Name:MAKALA, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:MAKALA
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 1:566 OAK BROOK DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4100
Mailing Address - Country:US
Mailing Address - Phone:706-504-1884
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD 4TH FLOOR, MEB
Practice Address - Street 2:CMC/LEVINE CHILDREN'S HOSPITAL
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-381-6800
Practice Address - Fax:704-381-6841
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC250694208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC250694Medicaid