Provider Demographics
NPI:1124005681
Name:FAYEMIWO, DEBO A
Entity Type:Individual
Prefix:MR
First Name:DEBO
Middle Name:A
Last Name:FAYEMIWO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 7TH ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5680
Mailing Address - Country:US
Mailing Address - Phone:909-948-6808
Mailing Address - Fax:909-948-6844
Practice Address - Street 1:9500 7TH ST
Practice Address - Street 2:SUITE F
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5680
Practice Address - Country:US
Practice Address - Phone:909-948-6808
Practice Address - Fax:909-948-6844
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3859490001Medicare ID - Type UnspecifiedDURABLE MEDICAL EQUIPMENT