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NPI Code Detail

MEDICARE: INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A.

MEDICARE: INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A.
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
1207R00000XInternal Medicine Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10033EVOTHERTXBCBS

General Provider Information

NPI Number : 1841259421
Entity Type Code : Organization
Provider Name (Legal Business Name) : INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A.
Provider Business Mailing Address
First Line : 2727 BOLTON BOONE DR
Second Line : 102
City : DESOTO
State : TX
Zip : 75115-2019
Country : US
Telephone Number : 972-283-8777
Fax Number : 972-283-9333
Provider Business Practice Location Address
First Line : 2727 BOLTON BOONE DR
Second Line : 102
City : DESOTO
State : TX
Zip : 75115-2019
Country : US
Telephone Number : 972-283-8777
Fax Number : 972-283-9333
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : DR. OLUBAYO AYOTUNDE IDOWU
Credential : M.D
Telephone Number : 972-283-8777
Provider Enumeration Date : 03/21/2006
Last Update Date : 08/22/2020

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Directions to “INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A. ” Practice Location

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