Provider Demographics
NPI:1265793616
Name:UDOSEN, ITAUMA (DO)
Entity type:Individual
Prefix:
First Name:ITAUMA
Middle Name:
Last Name:UDOSEN
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 1:2745 DEKALB MEDICAL PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4933
Mailing Address - Country:US
Mailing Address - Phone:770-593-2382
Mailing Address - Fax:
Practice Address - Street 1:2745 DEKALB MEDICAL PKWY STE 110
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4933
Practice Address - Country:US
Practice Address - Phone:770-593-2382
Practice Address - Fax:678-514-2527
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078910207Q00000X
GA78910207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine