Healthcare Provider Details

I. General information

NPI: 1164837514
Provider Name (Legal Business Name): OLUWAROTIMI OLUWAKEMI ADESINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 NEW SANGER AVE STE 516
WACO TX
76712-4054
US

IV. Provider business mailing address

PO BOX 18962
BELFAST ME
04915-4084
US

V. Phone/Fax

Practice location:
  • Phone: 254-752-9638
  • Fax:
Mailing address:
  • Phone: 800-566-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT207580
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberS1546
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberMT207580
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberS1546
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: