Provider Demographics
NPI:1730230426
Name:FAMUYIDE, AYODEJI O (MED, PT, FAAOMPT)
Entity type:Individual
Prefix:MR
First Name:AYODEJI
Middle Name:O
Last Name:FAMUYIDE
Suffix:
Gender:M
Credentials:MED, PT, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45985
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895-4985
Mailing Address - Country:US
Mailing Address - Phone:225-248-0085
Mailing Address - Fax:225-248-0086
Practice Address - Street 1:3676 HARDING BLVD STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-5259
Practice Address - Country:US
Practice Address - Phone:225-454-6005
Practice Address - Fax:225-454-6018
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03314F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5X657Medicare PIN