Provider Demographics
NPI:1245736172
Name:DEFORE, SALOME EWURASI (MD)
Entity Type:Individual
Prefix:DR
First Name:SALOME
Middle Name:EWURASI
Last Name:DEFORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALOME
Other - Middle Name:EWURASI
Other - Last Name:DADZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:470-316-3378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88578208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program