Provider Demographics
NPI:1336239177
Name:MIMIKO, OLUBANSILE A (MD)
Entity Type:Individual
Prefix:
First Name:OLUBANSILE
Middle Name:A
Last Name:MIMIKO
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:P O BOX 4128
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-4128
Mailing Address - Country:US
Mailing Address - Phone:478-374-2742
Mailing Address - Fax:
Practice Address - Street 1:521 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6712
Practice Address - Country:US
Practice Address - Phone:478-374-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH59599Medicare UPIN