Basic Information
| Provider Information | |||||||||
| NPI: | 1033645734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NSOFOR | ||||||||
| FirstName: | ECHEZONA | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4053 WORTHAM WAY | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300346251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073177704 | ||||||||
| FaxNumber: | 6622225277 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 WESTVIEW DRIVE SW | ||||||||
| Address2: | MOREHOUSE SCHOOL OF MEDICINE/GME | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561368 | ||||||||
| FaxNumber: | 4047561313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/06/2017 | ||||||||
| NPIReactivationDate: | 06/04/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 83514 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.