Provider Demographics
NPI:1588857304
Name:EJAIFE-AUSTIN, GRACE IVIE (DPM)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:IVIE
Last Name:EJAIFE-AUSTIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 N HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-1505
Mailing Address - Country:US
Mailing Address - Phone:478-328-6466
Mailing Address - Fax:478-328-1338
Practice Address - Street 1:1043 N HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-1505
Practice Address - Country:US
Practice Address - Phone:478-328-6466
Practice Address - Fax:478-328-1338
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001084213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist