Provider Demographics
NPI:1346801362
Name:ODOGWU, CHISOM CHIJIOKE
Entity Type:Individual
Prefix:
First Name:CHISOM
Middle Name:CHIJIOKE
Last Name:ODOGWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N PARK PL STE 101
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7237
Mailing Address - Country:US
Mailing Address - Phone:770-758-7493
Mailing Address - Fax:
Practice Address - Street 1:135 N PARK PL STE 101
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7237
Practice Address - Country:US
Practice Address - Phone:770-758-7493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty