Provider Demographics
NPI:1265482285
Name:FABAYO, ADESOLA OMOTAYO (MD)
Entity Type:Individual
Prefix:DR
First Name:ADESOLA
Middle Name:OMOTAYO
Last Name:FABAYO
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 1:610 S 8TH ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4201
Mailing Address - Country:US
Mailing Address - Phone:770-228-8550
Mailing Address - Fax:770-228-1478
Practice Address - Street 1:610 S 8TH ST
Practice Address - Street 2:SUITE F
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4201
Practice Address - Country:US
Practice Address - Phone:770-228-8550
Practice Address - Fax:770-228-1478
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45782103TB0200X
GA045782207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000870669BMedicaid
GA00870669AMedicaid
GA00870669AMedicaid