=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023172061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIMBOLA MICHAEL BANJO M.D.,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 W GOODWIN ST
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78064-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-569-2440
-----------------------------------------------------
Fax | 830-281-4300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 146
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78064-0146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-569-2440
-----------------------------------------------------
Fax | 830-281-4300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | J9620
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------