Provider Demographics
NPI:1306394150
Name:OHAYAGHA, RAPHAEL (MBA)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:OHAYAGHA
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 922511
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30010-2511
Mailing Address - Country:US
Mailing Address - Phone:770-885-8791
Mailing Address - Fax:
Practice Address - Street 1:6394 CRESTLINE TER APT C
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3884
Practice Address - Country:US
Practice Address - Phone:770-885-8791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA154726171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor