Healthcare Provider Details

I. General information

NPI: 1306832456
Provider Name (Legal Business Name): KEHINDE A LAYENI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/13/2006

III. Provider practice location address

1691 MAYO DR
TAVARES FL
32778-4301
US

IV. Provider business mailing address

1691 MAYO DR
TAVARES FL
32778-4301
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-0003
  • Fax: 352-253-0016
Mailing address:
  • Phone: 352-253-0003
  • Fax: 352-253-0016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0062765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: