Provider Demographics
NPI:1144487018
Name:EFOBI, ELLIS IFEANYICHUKWU (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:IFEANYICHUKWU
Last Name:EFOBI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1525 E. PARK PLACE BLVD.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3453
Mailing Address - Country:US
Mailing Address - Phone:770-879-7707
Mailing Address - Fax:770-879-7708
Practice Address - Street 1:1525 E. PARK PLACE BLVD.
Practice Address - Street 2:SUITE 300
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3453
Practice Address - Country:US
Practice Address - Phone:770-879-7707
Practice Address - Fax:770-879-7708
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2011-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA060727208D00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA594981959AMedicaid