=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437444007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AKEEM OLABANJI ADEBOGUN MD, MPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2011
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12001 SOUTH FWY STE 300
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-7215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-268-6670
-----------------------------------------------------
Fax | 682-268-6671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3170 KETTERING BLVD BLDG B3
-----------------------------------------------------
City | MORAINE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45439-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-991-3188
-----------------------------------------------------
Fax | 937-223-9811
-----------------------------------------------------
=====================================================
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 | T9044
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD044027
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 35.126515
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 3211
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------