Provider Demographics
NPI:1235349341
Name:FAKUNLE, ABAYOMI
Entity Type:Individual
Prefix:DR
First Name:ABAYOMI
Middle Name:
Last Name:FAKUNLE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ABAYOMI
Other - Middle Name:
Other - Last Name:FAKUNLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:13318 ROYDEN CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-1218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1808 WOODLAWN DR
Practice Address - Street 2:SUITE M
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4023
Practice Address - Country:US
Practice Address - Phone:410-298-3482
Practice Address - Fax:410-298-0314
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25326174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3145 AMedicare ID - Type Unspecified