Provider Demographics
NPI:1902832397
Name:FASEHUN, TAIWO M (MD)
Entity Type:Individual
Prefix:DR
First Name:TAIWO
Middle Name:M
Last Name:FASEHUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3625 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5434
Mailing Address - Country:US
Mailing Address - Phone:815-385-8560
Mailing Address - Fax:815-385-8568
Practice Address - Street 1:3625 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5434
Practice Address - Country:US
Practice Address - Phone:815-385-8560
Practice Address - Fax:815-385-8568
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036087368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087368Medicaid
IL036087368Medicaid