Provider Demographics
NPI:1689622128
Name:ADEBISI, OMONIYI YAKUBU (MD, DABFP)
Entity Type:Individual
Prefix:DR
First Name:OMONIYI
Middle Name:YAKUBU
Last Name:ADEBISI
Suffix:
Gender:M
Credentials:MD, DABFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:TALLAPOOSA
Mailing Address - State:GA
Mailing Address - Zip Code:30176-0215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 COVINGTON PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5048
Practice Address - Country:US
Practice Address - Phone:901-383-8889
Practice Address - Fax:901-383-2245
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38880207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3896669Medicaid