Healthcare Provider Details

I. General information

NPI: 1518952142
Provider Name (Legal Business Name): ADEBOWALE ANSELM OBAITAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 LUCKENBACH DR
ALLEN TX
75013-4632
US

IV. Provider business mailing address

1430 LUCKENBACH DR
ALLEN TX
75013-4632
US

V. Phone/Fax

Practice location:
  • Phone: 972-390-8133
  • Fax: 972-390-9258
Mailing address:
  • Phone: 972-390-8133
  • Fax: 972-390-9258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number051994
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM6319
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: