Provider Demographics
NPI:1154534303
Name:OTUGUOR, AKPOMUDIARE SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:AKPOMUDIARE
Middle Name:SAMUEL
Last Name:OTUGUOR
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 1:535 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354-1603
Mailing Address - Country:US
Mailing Address - Phone:404-761-4040
Mailing Address - Fax:404-761-4008
Practice Address - Street 1:535 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-1603
Practice Address - Country:US
Practice Address - Phone:404-761-4040
Practice Address - Fax:404-761-4008
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.38189207P00000X
MI4301086102207Q00000X
GA65599207Q00000X
AL38189208M00000X
IA38788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
I10723009Medicare PIN