Provider Demographics
NPI:1043567423
Name:OMOYENI, JADESOLA I (MD)
Entity Type:Individual
Prefix:
First Name:JADESOLA
Middle Name:I
Last Name:OMOYENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JADESOLA
Other - Middle Name:I
Other - Last Name:FAPOHUNDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1804 NE LOOP 410 STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5211
Mailing Address - Country:US
Mailing Address - Phone:210-614-1234
Mailing Address - Fax:
Practice Address - Street 1:1804 NE LOOP 410 STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5211
Practice Address - Country:US
Practice Address - Phone:210-614-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-05
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6776207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX385652801Medicaid
TX385652802Medicaid