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General NPI Number Information
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NPI Number | 1851432462
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Entity Type | Organization
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Legal Business Name | FORT WORTH INTERNAL MEDICINE PA
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Dates
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Enumeration Date | 02/08/2007
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Last Update Date | 06/17/2015
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Provider Practice Location Address
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Address Line | 654 SAINT LOUIS AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3358
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Country | US
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Telephone | 817-386-9818
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Fax |
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Provider Business Mailing Address
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Address Line | 654 SAINT LOUIS AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3358
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Country | US
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Telephone | 817-386-9818
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. ADEBOLA SULAIMAN OLATUNJI
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Credential | MD
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Telephone | 817-386-9818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | L9833
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License Number State | TX
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