Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 207287 | NY |
N | 111NI0900X | Internist | 207287 | NY |
N | 207RA0401X | Internist - Addiction Medicine | 207287 | NY |
NPI | 1306913371 |
---|---|
Provider Name | Moronkeji Olapade Fagbemi |
First Address | Valley Stream, NY 11580-4944 |
Second Address | Valley Stream, NY 11580-4944 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02073027 | (05) | NY |
207287 | LICENSE (01) | NY |
HO4366 | (02) | NY |