Provider Demographics
NPI:1497793970
Name:BABALOLA, ADENIYI CAXTON (MD)
Entity Type:Individual
Prefix:
First Name:ADENIYI
Middle Name:CAXTON
Last Name:BABALOLA
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 1:107 WESTWARD DR UNIT 661112
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33266-0649
Mailing Address - Country:US
Mailing Address - Phone:305-321-5578
Mailing Address - Fax:
Practice Address - Street 1:285 BOULEVARD NE STE 435
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4213
Practice Address - Country:US
Practice Address - Phone:404-222-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80177207R00000X
PAMD430588207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101907124Medicaid
PA110740Medicare PIN