Provider Demographics
NPI:1407879109
Name:FAKIYESI, OLUTOPE (MD)
Entity Type:Individual
Prefix:
First Name:OLUTOPE
Middle Name:
Last Name:FAKIYESI
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 1:1375 MCDIVITT DR
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-3357
Mailing Address - Country:US
Mailing Address - Phone:610-524-1552
Mailing Address - Fax:
Practice Address - Street 1:225 NEWTOWN ROAD
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974
Practice Address - Country:US
Practice Address - Phone:215-441-6600
Practice Address - Fax:215-441-6891
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064023L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0532414000OtherPERSONAL CHOICE
PA0017956240005Medicaid
PA260048344OtherRAILROAD MEDICARE
PA261126000OtherMIS
PA0532414000OtherPERSONAL CHOICE
PA0017956240005Medicaid