Healthcare Provider Details

I. General information

NPI: 1245509108
Provider Name (Legal Business Name): ADEBAYO ADEWALE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 S LOOP 256 STE F
PALESTINE TX
75801-8493
US

IV. Provider business mailing address

4002 S LOOP 256 STE F
PALESTINE TX
75801-8493
US

V. Phone/Fax

Practice location:
  • Phone: 903-723-8210
  • Fax: 903-723-8310
Mailing address:
  • Phone: 903-723-8210
  • Fax: 903-723-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number267748
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberQ0394
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: