1871842161 NPI number — MRS. OLUBUSOLA TEMIDAYO DARAMOLA

Table of content: MRS. OLUBUSOLA TEMIDAYO DARAMOLA (NPI 1871842161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871842161 NPI number — MRS. OLUBUSOLA TEMIDAYO DARAMOLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DARAMOLA
Provider First Name:
OLUBUSOLA
Provider Middle Name:
TEMIDAYO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1871842161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6080 S HULEN ST
Provider Second Line Business Mailing Address:
SUITE 360 PMB 229
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76132-2622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-426-2306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 WALLS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEBURNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76033-4045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-645-0668
Provider Business Practice Location Address Fax Number:
817-645-0720
Provider Enumeration Date:
09/03/2012

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: 363LF0000X , with the licence number:  824556 , 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: DO7564 . This is a "RR GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01111340 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2035487-04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3089625-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890N47 . This is a "BCBS PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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