Provider Demographics
NPI:1063521979
Name:EGBEWATT, AGBOR NDIPARREY (MD)
Entity type:Individual
Prefix:
First Name:AGBOR
Middle Name:NDIPARREY
Last Name:EGBEWATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 OLD NORCROSS ROAD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8703
Mailing Address - Country:US
Mailing Address - Phone:770-338-5070
Mailing Address - Fax:
Practice Address - Street 1:555 OLD NORCROSS ROAD
Practice Address - Street 2:SUITE 130
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8703
Practice Address - Country:US
Practice Address - Phone:770-338-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038744207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00631463CMedicaid
GA11BDRQPMedicare ID - Type Unspecified
GA00631463CMedicaid