Healthcare Provider Details

I. General information

NPI: 1699087403
Provider Name (Legal Business Name): BABAJIDE EYITAYO FADITAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MERCANTILE LN STE 217
LARGO MD
20774-5388
US

IV. Provider business mailing address

1450 MERCANTILE LN STE 217
LARGO MD
20774-5388
US

V. Phone/Fax

Practice location:
  • Phone: 301-341-5000
  • Fax: 301-341-5001
Mailing address:
  • Phone: 301-341-5000
  • Fax: 301-341-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD74464
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier378100300
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: