Healthcare Provider Details

I. General information

NPI: 1134416522
Provider Name (Legal Business Name): AYORINDE OLATOKUNBO OGUNBAMERU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: AYORINDE OLATOKUNBO OGUNBAMERU M.D

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SOLANA BLVD STE 2200
ROANOKE TX
76262-1769
US

IV. Provider business mailing address

1301 SOLANA BLVD STE 2200
ROANOKE TX
76262-1769
US

V. Phone/Fax

Practice location:
  • Phone: 817-693-5486
  • Fax: 817-717-6569
Mailing address:
  • Phone: 817-693-5486
  • Fax: 817-717-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT1500
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: