Provider Demographics
NPI:1134128101
Name:FATIREGUN, AGBOOLA O (MD)
Entity Type:Individual
Prefix:
First Name:AGBOOLA
Middle Name:O
Last Name:FATIREGUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N MACARTHUR BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3675
Mailing Address - Country:US
Mailing Address - Phone:972-256-3700
Mailing Address - Fax:866-630-6348
Practice Address - Street 1:3501 N MACARTHUR BLVD STE 450
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3651
Practice Address - Country:US
Practice Address - Phone:972-786-0330
Practice Address - Fax:972-739-2894
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220389208000000X
TXM7173208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189208501Medicaid
TX8W4546OtherBLUE CROSS
TX189208501Medicaid
NYH76133Medicare UPIN