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General NPI Number Information
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NPI Number | 1841571841
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Entity Type | Individual
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Provider Name | MR. OMOTOLA KEHINDE AJIBADE
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Gender | Male
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Dates
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Enumeration Date | 09/02/2011
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 2160 S 1ST AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-3328
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Country | US
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Telephone | 708-216-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 1055 HOWELL MILL RD NW FL 8
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City | ATLANTA
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State | GA
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Zip | 30318-5557
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Country | US
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Telephone | 678-470-1562
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036167010
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 25MA11363300
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 94515
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License Number State | GA
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