Provider Demographics
NPI:1649234055
Name:AGBEYEGBE, KINGSLEY E (MD)
Entity Type:Individual
Prefix:DR
First Name:KINGSLEY
Middle Name:E
Last Name:AGBEYEGBE
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 1:1151 CLEVELAND AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3600
Mailing Address - Country:US
Mailing Address - Phone:404-305-0004
Mailing Address - Fax:404-305-0494
Practice Address - Street 1:1151 CLEVELAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3600
Practice Address - Country:US
Practice Address - Phone:404-305-0004
Practice Address - Fax:404-305-0494
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047562207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000848262DMedicaid
GA000848262DMedicaid