Healthcare Provider Details

I. General information

NPI: 1174942643
Provider Name (Legal Business Name): OLUBADEWA FATUNDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 E BAYWOOD AVE STE 301
MESA AZ
85206-1749
US

IV. Provider business mailing address

6343 E MAIN ST STE 12
MESA AZ
85205-8955
US

V. Phone/Fax

Practice location:
  • Phone: 480-835-6100
  • Fax: 480-461-4243
Mailing address:
  • Phone: 480-835-6100
  • Fax: 480-461-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10060986
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number60929
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number60929
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: