Provider Demographics
NPI:1316938848
Name:AYULO, MARCO A SR (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:A
Last Name:AYULO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5316
Mailing Address - Country:US
Mailing Address - Phone:912-283-6152
Mailing Address - Fax:912-283-5264
Practice Address - Street 1:207 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2550
Practice Address - Country:US
Practice Address - Phone:478-275-1111
Practice Address - Fax:478-488-3477
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA036088207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00516612FMedicaid
GA00516612AMedicaid
GA83BBBBMMedicare ID - Type Unspecified