Healthcare Provider Details

I. General information

NPI: 1548407034
Provider Name (Legal Business Name): AYOTOKUNBO OLOSUNDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5002 COWHORN CREEK RD
TEXARKANA TX
75503-9766
US

IV. Provider business mailing address

5002 COWHORN CREEK RD
TEXARKANA TX
75503-9766
US

V. Phone/Fax

Practice location:
  • Phone: 903-614-3000
  • Fax: 903-614-3525
Mailing address:
  • Phone: 903-614-3000
  • Fax: 903-614-3525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberP1121
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: