Healthcare Provider Details

I. General information

NPI: 1457359663
Provider Name (Legal Business Name): OLUYEMISI JOKOTADE FATUNDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

IV. Provider business mailing address

1400 WALLACE BLVD
AMARILLO TX
79106-1708
US

V. Phone/Fax

Practice location:
  • Phone: 806-414-9800
  • Fax: 806-354-5689
Mailing address:
  • Phone: 806-414-9800
  • Fax: 806-354-5689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC51242
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberFTL 42897
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN6289
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: