Provider Demographics
NPI:1336190776
Name:AGBAJE, ISMAILU O (PHD MD)
Entity Type:Individual
Prefix:
First Name:ISMAILU
Middle Name:O
Last Name:AGBAJE
Suffix:
Gender:M
Credentials:PHD MD
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 73200
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3200
Mailing Address - Country:US
Mailing Address - Phone:812-272-4497
Mailing Address - Fax:419-828-8218
Practice Address - Street 1:2101 NEWNAN CROSSING BLVD E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2406
Practice Address - Country:US
Practice Address - Phone:812-272-4497
Practice Address - Fax:419-828-8218
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72872208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200999480Medicaid
OH203391625027OtherCARESOURCE
OHP00279240OtherRR MEDICARE PTAN
I16571Medicare UPIN
OHP00279240Medicare PIN
OH2507317Medicaid
OH4142682Medicare PIN
OH000000397175OtherANTHEM BCBS
OH735203OtherBUCKEYE COMMUNITY HEALTH
OH$$$$$$$$$00OtherOHIO BUREAU OF WORKERS COMP
OH$$$$$$$$$002OtherMEDICAL MUTUAL