Provider Demographics
NPI:1154811958
Name:NDEM, IDORENYIN EKA-IMO (MD)
Entity type:Individual
Prefix:
First Name:IDORENYIN
Middle Name:EKA-IMO
Last Name:NDEM
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 1:975 JOHNSON FERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1618
Mailing Address - Country:US
Mailing Address - Phone:404-785-7792
Mailing Address - Fax:919-966-3814
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:404-785-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238506390200000X
GA1006412086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program