Provider Demographics
NPI:1285820118
Name:FADEYI, EMMANUEL ADEGOKE (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ADEGOKE
Last Name:FADEYI
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-7595
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-7595
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01579207ZC0006X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908038Medicaid
NC1464TOtherBCBS
NC5908038Medicaid