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General NPI Number Information
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NPI Number | 1104822097
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Entity Type | Individual
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Provider Name | OLADELE ADEPITAN ADEBOGUN MD. PA.
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Gender | Male
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Dates
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Enumeration Date | 06/24/2005
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Last Update Date | 01/24/2019
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Provider Practice Location Address
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Address Line | 2620 LONG PRAIRIE RD STE 100
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City | FLOWER MOUND
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State | TX
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Zip | 75022-4953
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Country | US
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Telephone | 972-221-7900
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Fax | 972-221-7900
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Provider Business Mailing Address
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Address Line | 2904 ARKANSAS BLVD
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City | TEXARKANA
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State | AR
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Zip | 71854-2536
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Country | US
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Telephone | 870-773-4655
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Fax | 870-772-4650
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number | N6128
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | E-1599
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | N6128
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License Number State | TX
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