Healthcare Provider Details

I. General information

NPI: 1922047422
Provider Name (Legal Business Name): ADEYINKA ADEBAYO AGBETOYIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/28/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2968 NORTH HIGHLAND AVE
JACKSON TN
38305
US

IV. Provider business mailing address

2968 NORTH HIGHLAND AVENUE SUITE A
JACKSON TN
38305-3609
US

V. Phone/Fax

Practice location:
  • Phone: 731-256-1819
  • Fax: 731-664-4330
Mailing address:
  • Phone: 731-256-1819
  • Fax: 731-664-4330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36918
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: