Provider Demographics
NPI:1942244017
Name:AJIBADE, CALEB DURO (MD)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:DURO
Last Name:AJIBADE
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 1:176 SPRINGFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1673
Mailing Address - Country:US
Mailing Address - Phone:478-731-0185
Mailing Address - Fax:
Practice Address - Street 1:176 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1673
Practice Address - Country:US
Practice Address - Phone:478-731-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044390207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA93BBJGCMedicare ID - Type Unspecified
GAG81493Medicare UPIN