Provider Demographics
NPI:1629485883
Name:FAMOYEGUN, AKINJIDE
Entity Type:Individual
Prefix:
First Name:AKINJIDE
Middle Name:
Last Name:FAMOYEGUN
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 1:701 PINE ST APT 47
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-3150
Mailing Address - Country:US
Mailing Address - Phone:708-990-2168
Mailing Address - Fax:
Practice Address - Street 1:3701 BROADWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5613
Practice Address - Country:US
Practice Address - Phone:510-752-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist