Provider Demographics
NPI:1235185455
Name:ALLEN, KHADIJATU E (MD)
Entity Type:Individual
Prefix:
First Name:KHADIJATU
Middle Name:E
Last Name:ALLEN
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 1:204 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2908
Mailing Address - Country:US
Mailing Address - Phone:912-632-2952
Mailing Address - Fax:912-632-8682
Practice Address - Street 1:204 E 15TH ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510
Practice Address - Country:US
Practice Address - Phone:912-632-2952
Practice Address - Fax:912-632-8682
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA44669207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00963344BMedicaid
FL051722401Medicaid
FL11454CMedicare ID - Type Unspecified
GA00963344BMedicaid