Basic Information
| Provider Information | |||||||||
| NPI: | 1992749113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASIKA | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | IKWUME | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9280 HIGHWAY 5 | ||||||||
| Address2: | STE E | ||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301341501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 DEKALB MEDICAL PARKWAY | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045018700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 031871 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000406777Y | 05 | GA | MEDICAID | 000406777Z | 05 | GA | MEDICAID |