Provider Demographics
NPI:1831727379
Name:OKPONYIA, IFEOMA (MD)
Entity type:Individual
Prefix:
First Name:IFEOMA
Middle Name:
Last Name:OKPONYIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GREENWAY BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4338
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 201&203
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:770-459-4411
Practice Address - Fax:770-456-3785
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty