Basic Information
Provider Information | |||||||||
NPI: | 1861620353 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAKORI | ||||||||
FirstName: | YELENA | ||||||||
MiddleName: | RANIKA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HARRIS | ||||||||
OtherFirstName: | YELENA | ||||||||
OtherMiddleName: | RANIKA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 905 DIXIE ST | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708125831 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 905 DIXIE ST | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301174417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708125831 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2009 | ||||||||
LastUpdateDate: | 09/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116023998 | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 0116023998 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 068637 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.