Provider Demographics
NPI:1275615171
Name:IYAMU, KINGSLEY E (MD)
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:E
Last Name:IYAMU
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 1:1850 LAKE PARK DR SE
Mailing Address - Street 2:218
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-7647
Mailing Address - Country:US
Mailing Address - Phone:404-213-8526
Mailing Address - Fax:770-438-1125
Practice Address - Street 1:1850 LAKE PARK DR SE
Practice Address - Street 2:218
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7647
Practice Address - Country:US
Practice Address - Phone:404-213-8526
Practice Address - Fax:770-438-1125
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0444932084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000899808BMedicaid
GAH42969Medicare UPIN
GA000899808BMedicaid