MEDICARE: MR. ADE LATEEF ADEDOKUN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204R00000X	Electrodiagnostic Medicine Physician	K5755	TX
2	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	K5755	TX
3	208VP0000X	Pain Medicine Physician	K5755	TX
4	208100000X	Physical Medicine & Rehabilitation Physician	K5755	TX

General Provider Information

NPI Number	:	1467427054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADE LATEEF ADEDOKUN DO

Provider Business Mailing Address
First Line	:	P.O. BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8450
Fax Number	:	817-378-3699

Provider Business Practice Location Address
First Line	:	6116 OAKBEND TRL STE 112
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3926
Country	:	US
Telephone Number	:	817-423-9054
Fax Number	:	817-423-9719

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/21/2022

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