Healthcare Provider Details

I. General information

NPI: 1265482285
Provider Name (Legal Business Name): ADESOLA OMOTAYO FABAYO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S 8TH ST SUITE F
GRIFFIN GA
30224-4201
US

IV. Provider business mailing address

610 S 8TH ST SUITE F
GRIFFIN GA
30224-4201
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-8550
  • Fax: 770-228-1478
Mailing address:
  • Phone: 770-228-8550
  • Fax: 770-228-1478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number45782
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number045782
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number045782
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: