Provider Demographics
NPI:1942554936
Name:OBUNADIKE, EZIAMAKA (MD)
Entity type:Individual
Prefix:
First Name:EZIAMAKA
Middle Name:
Last Name:OBUNADIKE
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 1:11655 FOREST LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-7304
Mailing Address - Country:US
Mailing Address - Phone:773-853-8141
Mailing Address - Fax:
Practice Address - Street 1:1968 HAWKS LN NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2283
Practice Address - Country:US
Practice Address - Phone:404-778-7142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0810222081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine