1700119567 NPI number — MR. BABAJIDE ADETOKUNBO FAJEMISIN PA-C

Table of content: MR. BABAJIDE ADETOKUNBO FAJEMISIN PA-C (NPI 1700119567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700119567 NPI number — MR. BABAJIDE ADETOKUNBO FAJEMISIN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAJEMISIN
Provider First Name:
BABAJIDE
Provider Middle Name:
ADETOKUNBO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1700119567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 FAIR OAKS AVE STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-346-2455
Provider Business Mailing Address Fax Number:
626-639-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15791 BEAR VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HESPERIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92345-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-949-1231
Provider Business Practice Location Address Fax Number:
877-738-3841
Provider Enumeration Date:
09/11/2009

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: 363A00000X , with the licence number:  PA20295 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: EFF:10/29/12 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF:10/21/13-VICTORV , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01288530/DU5182 . This is a "RAILROAD MEDICARE-COLTON/VICTORVILLE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P01282519/DU4034 . This is a "RAILROAD MEDICARE-ADELANTO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EFF.10/21/13-COLTON , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF: 1/24/2013 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF: 1/18/13 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EFF: 1/18/2013 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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