Healthcare Provider Details

I. General information

NPI: 1083111546
Provider Name (Legal Business Name): OLUFISAYO FAGBEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-2060
  • Fax: 414-259-9290
Mailing address:
  • Phone: 414-805-2060
  • Fax: 414-259-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number74127
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: