Provider Demographics
NPI:1922154681
Name:FASHAKIN, EMMANUEL OLUSEGUN (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:OLUSEGUN
Last Name:FASHAKIN
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 1:7935 153RD ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3937
Mailing Address - Country:US
Mailing Address - Phone:718-591-1600
Mailing Address - Fax:718-591-0265
Practice Address - Street 1:7935 153RD ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3937
Practice Address - Country:US
Practice Address - Phone:718-591-1600
Practice Address - Fax:718-591-0265
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01652235Medicaid
NY01652235Medicaid
NYWAB431Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NYG26238Medicare UPIN