Provider Demographics
NPI:1124080288
Name:ADESANYA, ADEBOLA O (MD)
Entity type:Individual
Prefix:
First Name:ADEBOLA
Middle Name:O
Last Name:ADESANYA
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 1:4020 N MACARTHUR BLVD STE 122-228
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6419
Mailing Address - Country:US
Mailing Address - Phone:888-484-8123
Mailing Address - Fax:
Practice Address - Street 1:3101 N TARRANT PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-8601
Practice Address - Country:US
Practice Address - Phone:817-639-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1331207L00000X, 207R00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132360204Medicaid
TX132360208Medicaid
TX132360207Medicaid
G40003Medicare UPIN
TX132360204Medicaid
TX132360204Medicaid