Provider Demographics
NPI:1043837370
Name:ADEBAYO, OLUBUNMI EMMANUEL
Entity Type:Individual
Prefix:
First Name:OLUBUNMI
Middle Name:EMMANUEL
Last Name:ADEBAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MONTGOMERY PARK BLVD APT 1002
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3552
Mailing Address - Country:US
Mailing Address - Phone:219-757-1082
Mailing Address - Fax:
Practice Address - Street 1:2201 MONTGOMERY PARK BLVD APT 1002
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3552
Practice Address - Country:US
Practice Address - Phone:219-757-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2152151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant