Provider Demographics
NPI:1700823598
Name:FASHORO, OLATUBOSUN (MD)
Entity Type:Individual
Prefix:DR
First Name:OLATUBOSUN
Middle Name:
Last Name:FASHORO
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 1:323 S MINNESOTA ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1601
Mailing Address - Country:US
Mailing Address - Phone:218-281-9603
Mailing Address - Fax:218-281-9461
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:218-281-9603
Practice Address - Fax:218-281-9461
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9436208D00000X
MN49513207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00406999OtherRAILROAD MEDICARE
28040OtherBCBS ND
MN946L3FAOtherBCBS MN
MN946L3FAOtherBCBS MN
P00406999OtherRAILROAD MEDICARE
NDH94372Medicare UPIN
ND23368Medicare ID - Type Unspecified
MN110011251Medicare PIN
MN110011442Medicare PIN