Provider Demographics
NPI:1104054212
Name:FALEBITA, OPEYEMI ADEGBOYEGA (MD)
Entity type:Individual
Prefix:DR
First Name:OPEYEMI
Middle Name:ADEGBOYEGA
Last Name:FALEBITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 592449
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0172
Mailing Address - Country:US
Mailing Address - Phone:410-496-6441
Mailing Address - Fax:410-496-6448
Practice Address - Street 1:160 CREEKSIDE WAY STE 602
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6439
Practice Address - Country:US
Practice Address - Phone:830-387-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250355207Q00000X
MDD0074239207Q00000X
390200000X
TXQ2444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD132190100Medicaid
MD132190100Medicaid