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1568673556

NPI Code Detail

MEDICARE: SAMUEL ADEKUNLE ADEFEYISAN MD

MEDICARE: SAMUEL ADEKUNLE ADEFEYISAN MD

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	207L00000X	Anesthesiology Physician	MD.29707	AL
2	207L00000X	Anesthesiology Physician	83699	SC
3	208000000X	Pediatrics Physician	062934	GA
4	208000000X	Pediatrics Physician	MD.2009	AL
5	2080P0203X	Pediatric Critical Care Medicine Physician	062934	GA
6	2080P0203X	Pediatric Critical Care Medicine Physician	MD.29707	AL
7	207L00000X	Anesthesiology Physician	062934	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568673556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL ADEKUNLE ADEFEYISAN MD

Provider Business Mailing Address
First Line	:	4314 CLAYTON ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3433
Country	:	US
Telephone Number	:	214-708-9590
Fax Number	:

Provider Business Practice Location Address
First Line	:	4314 CLAYTON ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3433
Country	:	US
Telephone Number	:	214-708-9590
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	12/16/2024

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Directions to “ SAMUEL ADEKUNLE ADEFEYISAN MD” Practice Location

Language	Start Address	Practice Location

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