Healthcare Provider Details

I. General information

NPI: 1508833203
Provider Name (Legal Business Name): ABIMBOLA Y. AWODIPE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 AMELIA CT GERIATRIC CENTER & SENIOR SERVICES
DALLAS TX
75235-7706
US

IV. Provider business mailing address

PO BOX 660599
DALLAS TX
75266-0599
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL9610
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberL9610
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: