Provider Demographics
NPI:1477599314
Name:IHENACHO, NICHOLAS KEMDI (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:KEMDI
Last Name:IHENACHO
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:PO BOX 870828
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0021
Mailing Address - Country:US
Mailing Address - Phone:404-296-7695
Mailing Address - Fax:
Practice Address - Street 1:5329 MEMORIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3212
Practice Address - Country:US
Practice Address - Phone:404-296-7695
Practice Address - Fax:404-296-7696
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038149207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000727108DMedicaid
GAG34112Medicare UPIN