MEDICARE: C.FUNSHO FAGBOHUN,MD,PHD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	K3176	TX

General Provider Information

NPI Number	:	1932332426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C.FUNSHO FAGBOHUN,MD,PHD PA

Provider Business Mailing Address
First Line	:	1601 LIBERTY ST STE A
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-3252
Country	:	US
Telephone Number	:	281-342-6962
Fax Number	:	281-342-6963

Provider Business Practice Location Address
First Line	:	1601 LIBERTY ST STE A
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-3252
Country	:	US
Telephone Number	:	281-342-6962
Fax Number	:	281-342-6963

Authorized Official
Title or Position	:	OWNER
Name	:	DR. C FUNSHO FAGBOHUN
Credential	:	M.D., PH.D
Telephone Number	:	281-342-6962

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	03/19/2015

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