Healthcare Provider Details

I. General information

NPI: 1508111212
Provider Name (Legal Business Name): ADEBAYO AYODEJI FASANYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 GRAND AVE
FORT SMITH AR
72904-7028
US

IV. Provider business mailing address

4300 GRAND AVE
FORT SMITH AR
72904-7028
US

V. Phone/Fax

Practice location:
  • Phone: 479-208-4601
  • Fax: 833-764-3814
Mailing address:
  • Phone: 479-208-4601
  • Fax: 833-764-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberE-10794
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberE-10794
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: