1124080288 NPI number — ADEBOLA O ADESANYA MD

Table of content: ADEBOLA O ADESANYA MD (NPI 1124080288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124080288 NPI number — ADEBOLA O ADESANYA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADESANYA
Provider First Name:
ADEBOLA
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1124080288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 N MACARTHUR BLVD STE 122-228
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-6419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-484-8123
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 N TARRANT PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76177-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-639-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2006

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: 207L00000X , with the licence number:  K1331 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: K1331 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LC0200X , with the licence number: K1331 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 132360204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132360208 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132360207 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107672300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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