Healthcare Provider Details

I. General information

NPI: 1821470634
Provider Name (Legal Business Name): BOLAJOKO O FAYODA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3821 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4679
US

IV. Provider business mailing address

6700 MODESTO AVE NE APT 1028
ALBUQUERQUE NM
87113-3209
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number83325
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD2025-0657
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: