Provider Demographics
NPI:1952496770
Name:UDEJIOFOR, NKIRUKA J (MD)
Entity Type:Individual
Prefix:
First Name:NKIRUKA
Middle Name:J
Last Name:UDEJIOFOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NKIRUKA
Other - Middle Name:J
Other - Last Name:ONWUBIKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:750 TOWN PARK LANE
Practice Address - Street 2:KAISER PERMANENLE TOWN PARK COMPREHENSIVE MEDICAL CENTE
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-514-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061199A207Q00000X
GA059340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGA1145Medicaid
GA003104939BMedicaid
GA003104939AMedicaid
GAP00924822OtherRR MEDICARE
GA003104939BMedicaid