Healthcare Provider Details

I. General information

NPI: 1306913371
Provider Name (Legal Business Name): MORONKEJI OLAPADE FAGBEMI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 ALBERT CT
VALLEY STREAM NY
11580-4944
US

IV. Provider business mailing address

3 ALBERT CT
VALLEY STREAM NY
11580-4944
US

V. Phone/Fax

Practice location:
  • Phone: 516-285-5683
  • Fax: 516-285-1226
Mailing address:
  • Phone: 516-285-5683
  • Fax: 516-285-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207287
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number207287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: