Provider Demographics
NPI:1104260090
Name:FASUYI, OMOFOLARIN BABATUNJI (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:OMOFOLARIN
Middle Name:BABATUNJI
Last Name:FASUYI
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 MARTIN SPRINGS DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2982
Mailing Address - Country:US
Mailing Address - Phone:573-458-6326
Mailing Address - Fax:
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:SUITE 210
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2982
Practice Address - Country:US
Practice Address - Phone:573-458-6326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1104260090Medicaid