MEDICARE: TITILOLA SODE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician	S5781	TX
2	390200000X	Student in an Organized Health Care Education/Training Program		TX

General Provider Information

NPI Number	:	1003203381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITILOLA SODE

Provider Business Mailing Address
First Line	:	5310 HARVEST HILL RD
Second Line	:	STE 290
City	:	DALLAS
State	:	TX
Zip	:	75230-5826
Country	:	US
Telephone Number	:	214-420-0650
Fax Number	:	214-736-0512

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-7708
Country	:	US
Telephone Number	:	214-590-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	05/04/2020

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