Healthcare Provider Details

I. General information

NPI: 1003203381
Provider Name (Legal Business Name): TITILOLA SODE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD
DALLAS TX
75390-7708
US

IV. Provider business mailing address

5310 HARVEST HILL RD STE 290
DALLAS TX
75230-5826
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8000
  • Fax:
Mailing address:
  • Phone: 214-420-0650
  • Fax: 214-736-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberS5781
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: