Provider Demographics
NPI:1740264951
Name:ANUEBUNWA, THEODORE O (MD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:O
Last Name:ANUEBUNWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 DEKALB MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4996
Mailing Address - Country:US
Mailing Address - Phone:404-501-8492
Mailing Address - Fax:
Practice Address - Street 1:2801 DEKALB MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4996
Practice Address - Country:US
Practice Address - Phone:404-501-8492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063757207R00000X, 208M00000X
MI4301082889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4560846Medicaid
MIP00093807Medicare ID - Type UnspecifiedRAILROAD MEDICARE
H95643Medicare UPIN
OM03300029Medicare ID - Type Unspecified