Provider Demographics
NPI:1679142111
Name:AGBASIONWE, MUTIAT (MD)
Entity type:Individual
Prefix:DR
First Name:MUTIAT
Middle Name:
Last Name:AGBASIONWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MUTIAT
Other - Middle Name:
Other - Last Name:ENIKANOLAIYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6303 TIMBER VALLEY WAY SW
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-0220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2161 W SPRING ST STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3196
Practice Address - Country:US
Practice Address - Phone:770-267-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA98698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine