MEDICARE: DR. AGBOLADE O. ODUTAYO D.O.

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	207R00000X	Internal Medicine Physician	K6196	TX
2	207Q00000X	Family Medicine Physician	K6196	TX
3	207P00000X	Emergency Medicine Physician	K6196	TX

General Provider Information

NPI Number	:	1316992779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGBOLADE O. ODUTAYO D.O.

Provider Business Mailing Address
First Line	:	300 W 4TH ST
Second Line	:
City	:	CAMERON
State	:	TX
Zip	:	76520-2509
Country	:	US
Telephone Number	:	254-697-3100
Fax Number	:	254-697-3112

Provider Business Practice Location Address
First Line	:	300 W 4TH ST
Second Line	:
City	:	CAMERON
State	:	TX
Zip	:	76520-2509
Country	:	US
Telephone Number	:	254-697-3100
Fax Number	:	254-697-3112

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

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	01/29/2024

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