Provider Demographics
NPI:1124296132
Name:IFAFORE, ADEBOLA TEMITOPE (MD)
Entity type:Individual
Prefix:
First Name:ADEBOLA
Middle Name:TEMITOPE
Last Name:IFAFORE
Suffix:
Gender:F
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7522
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4966207P00000X
CT046170207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323250604Medicaid
TXP01246225OtherRAIL ROAD
TX323250602Medicaid
TX8DQ931OtherBCBS
TX8DQ932OtherBCBS
TXP01246215OtherRAIL ROAD
TXP01246267OtherRAIL ROAD
TXP01478949OtherRAIL ROAD
TX8DP930OtherBCBS
TX323250603Medicaid
TX323250601Medicaid
TX8FB278OtherBCBS
TX323250602Medicaid
TX297492YMAFMedicare PIN
TXP01246225OtherRAIL ROAD
TX297492YNSXMedicare PIN