Provider Demographics
NPI:1992797229
Name:OKOBAH, ISIOMA THERESA (MD)
Entity type:Individual
Prefix:DR
First Name:ISIOMA
Middle Name:THERESA
Last Name:OKOBAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2505 PANOLA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4831
Mailing Address - Country:US
Mailing Address - Phone:770-323-6458
Mailing Address - Fax:770-323-6462
Practice Address - Street 1:2505 PANOLA RD
Practice Address - Street 2:SUITE A
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4831
Practice Address - Country:US
Practice Address - Phone:770-323-6458
Practice Address - Fax:770-323-6462
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0566112084P0800X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA811209596AMedicaid