Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2081P2900X | Pain Medicine | 060727 | GA |
Y | 208D00000X | General Practice Physician | 060727 | GA |
NPI | 1144487018 |
---|---|
Provider Name | Dr. Ellis Ifeanyichukwu Efobi |
First Address | Stone Mountain, GA 30087-3453 |
Second Address | Stone Mountain, GA 30087-3453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2008 |
Last Update Date | 02/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
594981959A | (05) | GA |