Healthcare Provider Details

I. General information

NPI: 1982165155
Provider Name (Legal Business Name): ADEYEMI T GBOHUNMI M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 CAMP BOWIE BLVD
FORT WORTH TX
76116-7163
US

IV. Provider business mailing address

1301 E DEBBIE LN # 102-8
MANSFIELD TX
76063-3305
US

V. Phone/Fax

Practice location:
  • Phone: 708-505-9364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberT9873
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: