=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427141746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUWEBATU T ODUNSI-SHIYANBADE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 647 N MILLER RD STE B
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-6180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-760-7969
-----------------------------------------------------
Fax | 817-760-7976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35629
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75235-0629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-424-2213
-----------------------------------------------------
Fax | 142-312-1592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | M4404
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------