Provider Demographics
NPI:1851634554
Name:FAWIBE, OMOTAYO TEMITOPE (MD)
Entity Type:Individual
Prefix:DR
First Name:OMOTAYO
Middle Name:TEMITOPE
Last Name:FAWIBE
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3978 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-672-4680
Practice Address - Fax:260-458-5836
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS58942083X0100X, 2083P0901X, 2083X0100X, 208D00000X, 2083C0008X
IN01076903A2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice