Provider Demographics
NPI:1457587842
Name:MADU, NDIDI EUGENE (DO)
Entity type:Individual
Prefix:DR
First Name:NDIDI
Middle Name:EUGENE
Last Name:MADU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 HIGHWAY 138 SE STE 800
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2098
Mailing Address - Country:US
Mailing Address - Phone:770-929-0404
Mailing Address - Fax:770-929-0540
Practice Address - Street 1:1815 HIGHWAY 138 SE STE 800
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2098
Practice Address - Country:US
Practice Address - Phone:770-929-0404
Practice Address - Fax:770-929-0540
Is Sole Proprietor?:No
Enumeration Date:2009-05-31
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065703207Q00000X
GA65703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113173AMedicaid
GA003113173AMedicaid