Provider Demographics
NPI:1588734081
Name:AGBEBIYI, JONATHAN A (MD,CMHT,MBA)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:AGBEBIYI
Suffix:
Gender:M
Credentials:MD,CMHT,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22200 W 11 MILE RD # 3455
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-9991
Mailing Address - Country:US
Mailing Address - Phone:248-436-1959
Mailing Address - Fax:248-436-1978
Practice Address - Street 1:20755 GREENFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-436-1959
Practice Address - Fax:248-436-1978
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301041053207V00000X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP23540001Medicare PIN