1265002075 NPI number — DR. BAMIDELE ADEOYE FAGBOLA DNP, AGPCNP

Table of content: DR. BAMIDELE ADEOYE FAGBOLA DNP, AGPCNP (NPI 1265002075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265002075 NPI number — DR. BAMIDELE ADEOYE FAGBOLA DNP, AGPCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGBOLA
Provider First Name:
BAMIDELE
Provider Middle Name:
ADEOYE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP, AGPCNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265002075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRHAVEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02719-5252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-973-2000
Provider Business Mailing Address Fax Number:
508-973-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 PROSPECT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL RIVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02720-5281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-973-7766
Provider Business Practice Location Address Fax Number:
508-973-7753
Provider Enumeration Date:
06/25/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN2301773 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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