Healthcare Provider Details

I. General information

NPI: 1144717422
Provider Name (Legal Business Name): ADEWALE BAMIDELE OGUNOYE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2018
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W TERRELL AVE STE K230
FORT WORTH TX
76104-3104
US

IV. Provider business mailing address

713 E ANDERSON ST
WEATHERFORD TX
76086-5705
US

V. Phone/Fax

Practice location:
  • Phone: 469-233-6840
  • Fax: 817-598-4799
Mailing address:
  • Phone: 682-803-3381
  • Fax: 817-598-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1144717422
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberT0877
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT0877
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: