Healthcare Provider Details

I. General information

NPI: 1700054665
Provider Name (Legal Business Name): ADISA A TIJANI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9319 LBJ FWY STE 208G
DALLAS TX
75243-3450
US

IV. Provider business mailing address

PO BOX 741411
DALLAS TX
75374-1411
US

V. Phone/Fax

Practice location:
  • Phone: 214-575-0666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0066978
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: