Individual
OLUBANSILE A MIMIKO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
521 GRIFFIN AVE, EASTMAN, GA 31023-6712
(478) 374-4128
Mailing address
P O BOX 4128, EASTMAN, GA 31023-4128
(478) 374-2742
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
050663
GA
Other
Enumeration date
10/13/2006
Last updated
07/08/2007
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