=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275262057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MESQUITE MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5115 N GALLOWAY AVE STE 203
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-7535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-660-8554
-----------------------------------------------------
Fax | 214-660-8634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5115 N GALLOWAY AVE STE 203
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-7535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-660-8554
-----------------------------------------------------
Fax | 214-660-8634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ADEWUMI BAKARE
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 214-516-1495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------