Provider Demographics
NPI:1134129026
Name:AKOMOLAFE, ABIMBULA (MD)
Entity Type:Individual
Prefix:
First Name:ABIMBULA
Middle Name:
Last Name:AKOMOLAFE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PIEDMONT AVE
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-2544
Mailing Address - Country:US
Mailing Address - Phone:404-756-5271
Mailing Address - Fax:404-756-1402
Practice Address - Street 1:75 PIEDMONT AVE
Practice Address - Street 2:STE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2544
Practice Address - Country:US
Practice Address - Phone:404-756-1410
Practice Address - Fax:404-756-1495
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00842762AMedicaid
H07591Medicare UPIN
GA00842762AMedicaid