Provider Demographics
NPI:1841571841
Name:AJIBADE, OMOTOLA KEHINDE
Entity Type:Individual
Prefix:MR
First Name:OMOTOLA
Middle Name:KEHINDE
Last Name:AJIBADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 COLLEGE ST
Mailing Address - Street 2:STUDENT BOX 70
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 COLLEGE ST
Practice Address - Street 2:STUDENT BOX 70
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-1500
Practice Address - Country:US
Practice Address - Phone:478-501-3786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361670102084P0800X
NJ25MA113633002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry