Provider Demographics
NPI:1518993120
Name:FATADE, AYOKUNLE (DO)
Entity Type:Individual
Prefix:
First Name:AYOKUNLE
Middle Name:
Last Name:FATADE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-3747
Mailing Address - Country:US
Mailing Address - Phone:276-632-1856
Mailing Address - Fax:
Practice Address - Street 1:1 E MARKET ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3747
Practice Address - Country:US
Practice Address - Phone:276-632-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine