1356575054 NPI number — DR. LATIFAT TOSIN AGBEJA M.D

Table of content: DR. LATIFAT TOSIN AGBEJA M.D (NPI 1356575054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356575054 NPI number — DR. LATIFAT TOSIN AGBEJA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGBEJA
Provider First Name:
LATIFAT
Provider Middle Name:
TOSIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ABDULKADIR
Provider Other First Name:
LATIFAT
Provider Other Middle Name:
TOSIN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356575054
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2402 OSLER COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31707-0205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-438-3300
Provider Business Mailing Address Fax Number:
229-438-3384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2402 OSLER COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-0205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-438-3300
Provider Business Practice Location Address Fax Number:
229-438-3384
Provider Enumeration Date:
05/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  062304 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 318844885A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com