MEDICARE: DR. AYOMIDE OYINDAMOLA OSIBANJO OD

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	152W00000X	Optometrist	10393T	TX

General Provider Information

NPI Number	:	1528707064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AYOMIDE OYINDAMOLA OSIBANJO OD

Provider Business Mailing Address
First Line	:	4372 DULLES DR APT 7209
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3533
Country	:	US
Telephone Number	:	901-692-8350
Fax Number	:

Provider Business Practice Location Address
First Line	:	4372 DULLES DR APT 7209
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3533
Country	:	US
Telephone Number	:	901-692-8350
Fax Number	:

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

Provider Enumeration Date	:	06/02/2022
Last Update Date	:	06/21/2022

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