1588685770 NPI number — ADEKUNLE ADEKOLA MD

Table of content: ADEKUNLE ADEKOLA MD (NPI 1588685770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588685770 NPI number — ADEKUNLE ADEKOLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADEKOLA
Provider First Name:
ADEKUNLE
Provider Middle Name:
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:
1588685770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 ELM ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75057-3764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-222-3601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
475 ELM ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LEWISVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75057-3762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-222-3571
Provider Business Practice Location Address Fax Number:
214-222-3601
Provider Enumeration Date:
07/22/2006

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: 207RP1001X , with the licence number:  M9773 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: M9773 , 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: P00799177 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TPI 1979403-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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