=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952410037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL EMEKA ESEDEBE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 04/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3535 N BUCKNER BLVD STE 104
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75228-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-774-9111
-----------------------------------------------------
Fax | 214-774-9109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 FOREST BEND DR
-----------------------------------------------------
City | COPPELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75019-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | L0155
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | L0155
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------