Provider Demographics
NPI:1497913867
Name:MAKORI-NELSON, BENADETTE KERUBO (MD)
Entity Type:Individual
Prefix:
First Name:BENADETTE
Middle Name:KERUBO
Last Name:MAKORI-NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BENADETTE
Other - Middle Name:KERUBO
Other - Last Name:MAKORI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3950 AUSTELL RD
Mailing Address - Street 2:BOX 22
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1121
Mailing Address - Country:US
Mailing Address - Phone:470-732-4022
Mailing Address - Fax:470-732-4023
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:BOX 22
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:470-732-4022
Practice Address - Fax:470-732-4023
Is Sole Proprietor?:No
Enumeration Date:2008-06-01
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA074063208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program