Provider Demographics
NPI:1356575054
Name:AGBEJA, LATIFAT TOSIN (MD)
Entity type:Individual
Prefix:DR
First Name:LATIFAT
Middle Name:TOSIN
Last Name:AGBEJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATIFAT
Other - Middle Name:TOSIN
Other - Last Name:ABDULKADIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2402 OSLER COURT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-0205
Mailing Address - Country:US
Mailing Address - Phone:229-438-3300
Mailing Address - Fax:229-438-3384
Practice Address - Street 1:2402 OSLER COURT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0205
Practice Address - Country:US
Practice Address - Phone:229-438-3300
Practice Address - Fax:229-438-3384
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062304207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA318844885AMedicaid
GA2021089532Medicare PIN