Healthcare Provider Details

I. General information

NPI: 1851087548
Provider Name (Legal Business Name): IBIDAPO EMMANUEL AINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 SPINNAKER LN APT 13C
DETROIT MI
48207-5006
US

IV. Provider business mailing address

3320 SPINNAKER LN APT 13C
DETROIT MI
48207-5006
US

V. Phone/Fax

Practice location:
  • Phone: 404-528-4250
  • Fax:
Mailing address:
  • Phone: 404-528-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301514951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: