Provider Demographics
NPI:1568171676
Name:AJALLA, TOCHUKWU C
Entity Type:Individual
Prefix:
First Name:TOCHUKWU
Middle Name:C
Last Name:AJALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5451 MILLENIA LAKES BLVD APT 327
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-6315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4495
Practice Address - Country:US
Practice Address - Phone:352-720-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical