Provider Demographics
NPI:1932332426
Name:C.FUNSHO FAGBOHUN,MD,PHD PA
Entity Type:Organization
Organization Name:C.FUNSHO FAGBOHUN,MD,PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:FUNSHO
Authorized Official - Last Name:FAGBOHUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:281-342-6962
Mailing Address - Street 1:1601 LIBERTY ST STE A
Mailing Address - Street 2:
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 STE A
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3176207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty