Provider Demographics
NPI:1437441797
Name:ELOSIEBO-WALKER, RAVEN IFOMA (MD)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:IFOMA
Last Name:ELOSIEBO-WALKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 MONTREAL RD STE 411
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6932
Mailing Address - Country:US
Mailing Address - Phone:404-296-8000
Mailing Address - Fax:770-493-6842
Practice Address - Street 1:1462 MONTREAL RD STE 411
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6932
Practice Address - Country:US
Practice Address - Phone:404-296-8000
Practice Address - Fax:770-493-6842
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA74090207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program