Provider Demographics
NPI:1568040814
Name:MBANASO, ALOZIE AMARACHUKWU (DO)
Entity Type:Individual
Prefix:DR
First Name:ALOZIE
Middle Name:AMARACHUKWU
Last Name:MBANASO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:501 REDMOND RD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1415
Mailing Address - Country:US
Mailing Address - Phone:706-978-9854
Mailing Address - Fax:706-802-3963
Practice Address - Street 1:17 COLLINS DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2487
Practice Address - Country:US
Practice Address - Phone:770-386-9390
Practice Address - Fax:706-802-3963
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96777207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program