Provider Demographics
NPI:1386064814
Name:IBOAYA, AIWANE (DO)
Entity type:Individual
Prefix:
First Name:AIWANE
Middle Name:
Last Name:IBOAYA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1426
Mailing Address - Country:US
Mailing Address - Phone:404-352-2020
Mailing Address - Fax:
Practice Address - Street 1:1900 10TH AVE
Practice Address - Street 2:SUITE # 100
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3600
Practice Address - Country:US
Practice Address - Phone:706-571-1430
Practice Address - Fax:706-571-1604
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82949208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty