Provider Demographics
NPI:1902244221
Name:FANIYAN, ADETOUN
Entity Type:Individual
Prefix:
First Name:ADETOUN
Middle Name:
Last Name:FANIYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 W NORTHGATE DR
Mailing Address - Street 2:UNIT 217
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-8433
Mailing Address - Country:US
Mailing Address - Phone:347-355-3994
Mailing Address - Fax:
Practice Address - Street 1:3609 W NORTHGATE DR
Practice Address - Street 2:UNIT 217
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-8433
Practice Address - Country:US
Practice Address - Phone:347-355-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-09
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0057219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine