Provider Demographics
NPI:1306423025
Name:FATUROTI, OLUBUKOLA IDOWU
Entity type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:IDOWU
Last Name:FATUROTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLUBUKOLA
Other - Middle Name:IDOWU
Other - Last Name:AWONIYI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-746-7500
Mailing Address - Fax:
Practice Address - Street 1:1000 HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5303
Practice Address - Country:US
Practice Address - Phone:989-746-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301511200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program