Healthcare Provider Details

I. General information

NPI: 1235349341
Provider Name (Legal Business Name): DR. ABAYOMI FAKUNLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ABAYOMI FAKUNLE M.D.,

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 WOODLAWN DR SUITE M
BALTIMORE MD
21207-4023
US

IV. Provider business mailing address

13318 ROYDEN CT
ELLICOTT CITY MD
21042-1218
US

V. Phone/Fax

Practice location:
  • Phone: 410-298-3482
  • Fax: 410-298-0314
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD25326
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: