Provider Demographics
NPI:1871322388
Name:AJIBADE, PHILLIPS
Entity type:Individual
Prefix:
First Name:PHILLIPS
Middle Name:
Last Name:AJIBADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114-1127
Mailing Address - Country:US
Mailing Address - Phone:973-393-5153
Mailing Address - Fax:
Practice Address - Street 1:35 ROSS ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-1127
Practice Address - Country:US
Practice Address - Phone:973-393-5153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172V00000XOther Service ProvidersCommunity Health Worker