Provider Demographics
NPI:1831386036
Name:FAMORI, BENEDICT GBOLABO (MD)
Entity type:Individual
Prefix:DR
First Name:BENEDICT
Middle Name:GBOLABO
Last Name:FAMORI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BENEDICT
Other - Middle Name:GBOLABO
Other - Last Name:FAMORITADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:106 BLANCA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-2511
Mailing Address - Fax:719-587-1372
Practice Address - Street 1:106 BLANCA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-2511
Practice Address - Fax:719-587-1372
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46889208M00000X
LA390200000X
DEC1-0012550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18807313Medicaid
LA1076830Medicaid
CO18807313Medicaid