Provider Demographics
NPI:1902874027
Name:AYEDUN, AYODELE A (MD)
Entity Type:Individual
Prefix:
First Name:AYODELE
Middle Name:A
Last Name:AYEDUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1191
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1191
Mailing Address - Country:US
Mailing Address - Phone:912-237-4793
Mailing Address - Fax:
Practice Address - Street 1:717 BOHLER AVE
Practice Address - Street 2:FIRST IMEX CORP
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:912-237-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046732207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G64777Medicare UPIN
GA11SCFLCMedicare ID - Type Unspecified