Provider Demographics
NPI:1164708707
Name:FAYETTEVILLE FAMILY PHYSICIAN, PLLC
Entity Type:Organization
Organization Name:FAYETTEVILLE FAMILY PHYSICIAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HDAYATU
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-214-3999
Mailing Address - Street 1:6834 EAST GENESEE STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-214-3999
Mailing Address - Fax:347-772-3132
Practice Address - Street 1:6834 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1021
Practice Address - Country:US
Practice Address - Phone:315-214-3999
Practice Address - Fax:347-772-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2462581261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care