Provider Demographics
NPI:1255795886
Name:FAWOLE, TALIAT ABIODUN (MD)
Entity type:Individual
Prefix:DR
First Name:TALIAT
Middle Name:ABIODUN
Last Name:FAWOLE
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 1:7901 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-3542
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-09
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE336632084P0800X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program