Provider Demographics
NPI:1437267556
Name:FAGBAMILA, ADEYINKA MARK (BSC RPT)
Entity Type:Individual
Prefix:MR
First Name:ADEYINKA
Middle Name:MARK
Last Name:FAGBAMILA
Suffix:
Gender:M
Credentials:BSC RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26696 ISLEWORTH PT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5670
Mailing Address - Country:US
Mailing Address - Phone:313-492-1946
Mailing Address - Fax:248-799-7645
Practice Address - Street 1:20510 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1613
Practice Address - Country:US
Practice Address - Phone:313-534-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4693548Medicaid
MI4693548Medicaid