Basic Information
| Provider Information | |||||||||
| NPI: | 1023472925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTALUKA | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | UCHENNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EZEMENARI | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | UCHENNA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31 COLE LN | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301012745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703778572 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 304 TURNER MCCALL BLVD SW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301655621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065095000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2016 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 85850 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 08523334 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.