Healthcare Provider Details

I. General information

NPI: 1164908570
Provider Name (Legal Business Name): AYODEJI DELANO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 MOUNT ZION RD
MORROW GA
30260-2357
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI GARDENS FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 770-629-3217
  • Fax:
Mailing address:
  • Phone: 770-629-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number90281
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: