Provider Demographics
NPI:1083842637
Name:WEJULI, IRMA
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:
Last Name:WEJULI
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 1:6416 PEAKE RD
Mailing Address - Street 2:#18
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-3900
Mailing Address - Country:US
Mailing Address - Phone:478-238-5577
Mailing Address - Fax:478-238-6575
Practice Address - Street 1:6416 PEAKE ROAD
Practice Address - Street 2:#18
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-238-5577
Practice Address - Fax:478-238-6575
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001154213E00000X
NY274346213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPOD001154OtherSTATE LICENSE
GAPOD001154OtherSTATE LICENSE