Healthcare Provider Details

I. General information

NPI: 1679730329
Provider Name (Legal Business Name): FOLUSO A FAKOREDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N PEARMAN AVE
CLEVELAND MS
38732-3502
US

IV. Provider business mailing address

800 N PEARMAN AVE
CLEVELAND MS
38732-3502
US

V. Phone/Fax

Practice location:
  • Phone: 888-757-0838
  • Fax: 888-757-1835
Mailing address:
  • Phone: 888-757-0838
  • Fax: 888-757-1835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number23725
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: