Provider Demographics
NPI:1720651649
Name:FASUBA, OLUKAYODE
Entity Type:Individual
Prefix:
First Name:OLUKAYODE
Middle Name:
Last Name:FASUBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 HARKEY RD APT 8201
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5962
Mailing Address - Country:US
Mailing Address - Phone:252-347-1595
Mailing Address - Fax:
Practice Address - Street 1:6030 HARKEY RD APT 8201
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5962
Practice Address - Country:US
Practice Address - Phone:252-347-1595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17780208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation