Healthcare Provider Details

I. General information

NPI: 1053354696
Provider Name (Legal Business Name): DANIEL BOLORUNDURO FAGBUYI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 JESSE HILL JR DR SE
ATLANTA GA
30303-3032
US

IV. Provider business mailing address

35 JESSE HILL JR DR SE
ATLANTA GA
30303-3032
US

V. Phone/Fax

Practice location:
  • Phone: 301-404-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax: 301-404-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD428894
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: