Provider Demographics
NPI:1306913371
Name:FAGBEMI, MORONKEJI OLAPADE (MD)
Entity type:Individual
Prefix:
First Name:MORONKEJI
Middle Name:OLAPADE
Last Name:FAGBEMI
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 1:3 ALBERT CT
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4944
Mailing Address - Country:US
Mailing Address - Phone:516-285-5683
Mailing Address - Fax:516-285-1226
Practice Address - Street 1:3 ALBERT CT
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4944
Practice Address - Country:US
Practice Address - Phone:516-285-5683
Practice Address - Fax:516-285-1226
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207287207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02073027Medicaid
NY207287OtherLICENSE
NY02073027Medicaid
NYHO4366Medicare UPIN