Provider Demographics
NPI:1255759627
Name:IWUEKE, CHISOM C
Entity type:Individual
Prefix:
First Name:CHISOM
Middle Name:C
Last Name:IWUEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FERRY RD STE 660
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1608
Mailing Address - Country:US
Mailing Address - Phone:404-847-1592
Mailing Address - Fax:
Practice Address - Street 1:107 TIMBERLINE TRL
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-3067
Practice Address - Country:US
Practice Address - Phone:864-905-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA89076207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program