Provider Demographics
NPI:1427141746
Name:ODUNSI-SHIYANBADE, SUWEBATU T (MD)
Entity type:Individual
Prefix:DR
First Name:SUWEBATU
Middle Name:T
Last Name:ODUNSI-SHIYANBADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUWEBATU
Other - Middle Name:T
Other - Last Name:ODUNSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2213
Mailing Address - Fax:142-312-1592
Practice Address - Street 1:647 N MILLER RD STE B
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6180
Practice Address - Country:US
Practice Address - Phone:817-760-7969
Practice Address - Fax:817-760-7976
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4404207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP0147446OtherDPS
TXM4404OtherMEDICAL LICENSE
MN638925000Medicaid
MN638925000Medicaid
MNI71310Medicare UPIN
TXB09911404OtherDEA