Healthcare Provider Details

I. General information

NPI: 1356332845
Provider Name (Legal Business Name): ABIODUN FATIMA BALOGUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 FRANKLIN HEALTH CMNS
FARMINGTON ME
04938-6144
US

IV. Provider business mailing address

181 FRANKLIN HEALTH CMNS
FARMINGTON ME
04938-6144
US

V. Phone/Fax

Practice location:
  • Phone: 207-778-0482
  • Fax: 207-778-0133
Mailing address:
  • Phone: 207-778-0482
  • Fax: 207-778-0133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19061
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number054060
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31162
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD27622
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: