Basic Information
| Provider Information | |||||||||
| NPI: | 1174843833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IJAMAKINWA | ||||||||
| FirstName: | NIHINLOLAWA | ||||||||
| MiddleName: | OREOLUWA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADEGUNLE | ||||||||
| OtherFirstName: | LOLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2481 GEORGE BUSBEE PKWY NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301444961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704230000 | ||||||||
| FaxNumber: | 7704230131 | ||||||||
| Practice Location | |||||||||
| Address1: | 2481 GEORGE BUSBEE PKWY NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301444961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704230000 | ||||||||
| FaxNumber: | 7704230131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 69012 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.