Provider Demographics
NPI:1790947216
Name:ADEFISAN, OLUJIMI AYODELE (MD)
Entity Type:Individual
Prefix:
First Name:OLUJIMI
Middle Name:AYODELE
Last Name:ADEFISAN
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 1:2150 PEACHFORD RD STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6521
Mailing Address - Country:US
Mailing Address - Phone:770-674-0553
Mailing Address - Fax:770-674-0554
Practice Address - Street 1:2150 PEACHFORD RD STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6521
Practice Address - Country:US
Practice Address - Phone:770-674-0553
Practice Address - Fax:770-674-0554
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT 1859152084P0804X
GA0636232084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121311HMedicaid
GA003121311AMedicaid