Provider Demographics
NPI:1811997794
Name:MABO, ERIC AKONWI (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:AKONWI
Last Name:MABO
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-219-2627
Practice Address - Fax:770-219-7365
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09022900207R00000X
GA055263207R00000X, 208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA560938790BMedicaid
FL000628600Medicaid
FLP00712052OtherRR MEDICARE
FLBP643ZMedicare PIN
I30452Medicare UPIN
GA11SCFBPMedicare ID - Type Unspecified