Provider Demographics
NPI:1477647410
Name:ONYEGBULA, ANTHONY C (DO)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:C
Last Name:ONYEGBULA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7444 HANNOVER PKWY S
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9303
Mailing Address - Country:US
Mailing Address - Phone:770-629-2337
Mailing Address - Fax:770-629-5194
Practice Address - Street 1:7444 HANNOVER PKWY S
Practice Address - Street 2:SUITE 150
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9303
Practice Address - Country:US
Practice Address - Phone:770-629-2337
Practice Address - Fax:770-629-5194
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053348207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA696378996BMedicaid
GAGRP7305Medicare ID - Type UnspecifiedMEDICARE GROUP ID
GA696378996BMedicaid