Provider Demographics
NPI:1386662617
Name:MOH, BENEDETH UJU
Entity Type:Individual
Prefix:MRS
First Name:BENEDETH
Middle Name:UJU
Last Name:MOH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:OGO
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9411 S MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8705
Mailing Address - Country:US
Mailing Address - Phone:770-477-4755
Mailing Address - Fax:770-477-4758
Practice Address - Street 1:9411 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8705
Practice Address - Country:US
Practice Address - Phone:770-477-4755
Practice Address - Fax:770-477-4758
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031 R 0040374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA457729570DMedicaid
GA457729570DMedicaid