Provider Demographics
NPI:1891115465
Name:TIBALEKA, JUNE (MD)
Entity Type:Individual
Prefix:
First Name:JUNE
Middle Name:
Last Name:TIBALEKA
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 1:3375 SPRING HILL PKWY SE APT 318
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6805
Mailing Address - Country:US
Mailing Address - Phone:443-939-5848
Mailing Address - Fax:
Practice Address - Street 1:1825 HIGHWAY 34 E STE 1200
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6416
Practice Address - Country:US
Practice Address - Phone:770-502-2112
Practice Address - Fax:770-502-2113
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-0609207P00000X
390200000X
GA86579207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09809872Medicaid