Healthcare Provider Details

I. General information

NPI: 1245320480
Provider Name (Legal Business Name): BOLANLE O. GBADEBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9939 STATE HIGHWAY 151
SAN ANTONIO TX
78251-1900
US

IV. Provider business mailing address

7400 MERTON MINTER ST
SAN ANTONIO TX
78229-4404
US

V. Phone/Fax

Practice location:
  • Phone: 210-949-9702
  • Fax: 210-443-0333
Mailing address:
  • Phone: 920-217-0539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46201
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28814
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: