Healthcare Provider Details

I. General information

NPI: 1013204932
Provider Name (Legal Business Name): RUTH IYUN FAGBEMI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 S RAEFORD RD
FAYETTEVILLE NC
28304-6162
US

IV. Provider business mailing address

2300 RAMSEY ST
FAYETTEVILLE NC
28301-3856
US

V. Phone/Fax

Practice location:
  • Phone: 910-475-6185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMT200451
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47498
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR1524
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR1524
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: