Provider Demographics
NPI:1548216732
Name:OMONUWA, SHAKOORA CENA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAKOORA
Middle Name:CENA
Last Name:OMONUWA
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 1:1203 CLEVELAND AVE
Mailing Address - Street 2:STE 1-B
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3417
Mailing Address - Country:US
Mailing Address - Phone:404-767-8884
Mailing Address - Fax:404-768-3479
Practice Address - Street 1:1203 CLEVELAND AVE
Practice Address - Street 2:STE 1-B
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3417
Practice Address - Country:US
Practice Address - Phone:404-767-8884
Practice Address - Fax:404-768-3479
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F76050Medicare UPIN
GRP7019Medicare ID - Type Unspecified