Provider Demographics
NPI:1629016415
Name:FAGBOHUN, C. FUNSHO (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:C. FUNSHO
Middle Name:
Last Name:FAGBOHUN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 LIBERTY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-3252
Mailing Address - Country:US
Mailing Address - Phone:281-342-6962
Mailing Address - Fax:281-342-6963
Practice Address - Street 1:1601 LIBERTY ST
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3252
Practice Address - Country:US
Practice Address - Phone:281-342-6962
Practice Address - Fax:281-342-6963
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3176207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141965701Medicaid
TX141965701Medicaid
TX00844JMedicare ID - Type Unspecified