Healthcare Provider Details

I. General information

NPI: 1255968301
Provider Name (Legal Business Name): OLUWAFUNMISO IBUNKUN FAGBONGBE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 UNIVERSITY HOSPITAL DR
MOBILE AL
36617-2300
US

IV. Provider business mailing address

2451 UNIVERSITY HOSPITAL DR RM 714
MOBILE AL
36617-2300
US

V. Phone/Fax

Practice location:
  • Phone: 251-472-7207
  • Fax:
Mailing address:
  • Phone: 251-471-7207
  • Fax: 251-471-7468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number50792
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberT9103
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: