Healthcare Provider Details

I. General information

NPI: 1609104785
Provider Name (Legal Business Name): AYOTUNDE GREGORY FAWEYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15210 I-45 SOUTH SUITE 110
CONROE TX
77384-4105
US

IV. Provider business mailing address

500 MEDICAL CENTER BLVD STE 350
CONROE TX
77304-2878
US

V. Phone/Fax

Practice location:
  • Phone: 936-270-8655
  • Fax: 936-270-8739
Mailing address:
  • Phone: 936-270-8655
  • Fax: 936-270-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-01988
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28250
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME111094
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP4646
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: