Healthcare Provider Details

I. General information

NPI: 1629206941
Provider Name (Legal Business Name): FAUSAT A ADEDIJI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E. 41ST STREET OU DEPARTMENT OF PEDIATRICS
TULSA OK
74135
US

IV. Provider business mailing address

4502 E 41ST ST
TULSA OK
74135-9923
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3416
  • Fax: 918-660-3426
Mailing address:
  • Phone: 918-660-3416
  • Fax: 918-660-3426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27247
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: