Provider Demographics
NPI:1376252676
Name:FADAMIRO, OLAMIDE AYOMIPOSI
Entity Type:Individual
Prefix:
First Name:OLAMIDE
Middle Name:AYOMIPOSI
Last Name:FADAMIRO
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 1:718 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-7012
Mailing Address - Country:US
Mailing Address - Phone:347-204-0775
Mailing Address - Fax:
Practice Address - Street 1:718 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-7012
Practice Address - Country:US
Practice Address - Phone:347-204-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator