Provider Demographics
NPI:1679263917
Name:IZEVBIGIE, MOSES U
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:U
Last Name:IZEVBIGIE
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 1:5909 PROVIDENCE RUN
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-6112
Mailing Address - Country:US
Mailing Address - Phone:404-277-4596
Mailing Address - Fax:
Practice Address - Street 1:5909 PROVIDENCE RUN
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-6112
Practice Address - Country:US
Practice Address - Phone:404-277-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities