Provider Demographics
NPI:1073550919
Name:DELTA MEDICAL PA
Entity Type:Organization
Organization Name:DELTA MEDICAL PA
Other - Org Name:DELTA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOFOWOROLA
Authorized Official - Middle Name:
Authorized Official - Last Name:EKADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-412-8769
Mailing Address - Street 1:PO BOX 93869
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0118
Mailing Address - Country:US
Mailing Address - Phone:817-293-8797
Mailing Address - Fax:
Practice Address - Street 1:12001 SOUTH FWY
Practice Address - Street 2:SUITE 210
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7208
Practice Address - Country:US
Practice Address - Phone:817-293-8797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W561OtherMEDICARE
TXP00053593OtherRAILROAD MEDICARE
TXP00053593OtherRAILROAD MEDICARE