Healthcare Provider Details

I. General information

NPI: 1487281275
Provider Name (Legal Business Name): MARIAN SIMISOLA FAGBEMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax: 623-776-9419
Mailing address:
  • Phone: 623-878-2100
  • Fax: 623-776-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number72709
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: