Provider Demographics
NPI:1265698922
Name:OMERUAH, CHIAZOM C (DO)
Entity type:Individual
Prefix:
First Name:CHIAZOM
Middle Name:C
Last Name:OMERUAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 EAGLES LANDING PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5173
Mailing Address - Country:US
Mailing Address - Phone:770-389-3855
Mailing Address - Fax:770-474-8078
Practice Address - Street 1:1240 EAGLES LANDING PKWY STE 110
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5173
Practice Address - Country:US
Practice Address - Phone:770-389-3855
Practice Address - Fax:770-474-8078
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015547207Q00000X
ALDO.1225207Q00000X
GA75091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2984309OtherCIGNA
AL511-18690OtherBCBS
AL133889Medicaid
ALZ40098OtherVIVA HEALTH
AL102I088198Medicare PIN