Provider Demographics
NPI:1235320151
Name:AJIBOWO, OLALEKAN HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:OLALEKAN
Middle Name:HENRY
Last Name:AJIBOWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 POTTERY FACTORY DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-6682
Mailing Address - Country:US
Mailing Address - Phone:706-423-9449
Mailing Address - Fax:
Practice Address - Street 1:413 POTTERY FACTORY DR
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-6682
Practice Address - Country:US
Practice Address - Phone:706-423-9449
Practice Address - Fax:706-423-9443
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059896207R00000X, 208VP0014X, 208VP0000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012327700Medicaid
GA029471605EMedicaid
GA029471605KMedicaid
GA029471605LMedicaid
GA029471605MMedicaid
GA029471605IMedicaid
GA029471605CMedicaid
GA029471605JMedicaid
GA029471605KMedicaid
GA102I119769Medicare PIN
GA511I110474Medicare PIN
GA029471605IMedicaid
GA029471605MMedicaid