Provider Demographics
NPI:1023126190
Name:FATIREGUN, TEMITOPE OLUWOLE (BSC RPT)
Entity type:Individual
Prefix:MR
First Name:TEMITOPE
Middle Name:OLUWOLE
Last Name:FATIREGUN
Suffix:
Gender:M
Credentials:BSC RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28298 HOOVER RD
Mailing Address - Street 2:APT-4
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4121
Mailing Address - Country:US
Mailing Address - Phone:586-491-5551
Mailing Address - Fax:586-573-3499
Practice Address - Street 1:20510 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1613
Practice Address - Country:US
Practice Address - Phone:313-534-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4693557Medicaid
MIN83540002Medicare ID - Type Unspecified