Healthcare Provider Details

I. General information

NPI: 1144165739
Provider Name (Legal Business Name): ADEBOYE OPEOLUWA GRILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 U OF A WAY
TEXARKANA AR
71854-1419
US

IV. Provider business mailing address

413 N GARRISON AVE APT 303
FERRELVIEW MO
64163-1421
US

V. Phone/Fax

Practice location:
  • Phone: 870-779-6000
  • Fax:
Mailing address:
  • Phone: 857-576-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: