Provider Demographics
NPI:1073562419
Name:ODELOWO, MOBOLAJI (MD)
Entity Type:Individual
Prefix:
First Name:MOBOLAJI
Middle Name:
Last Name:ODELOWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S CONROE MEDICAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-5341
Mailing Address - Country:US
Mailing Address - Phone:936-539-4031
Mailing Address - Fax:936-539-4537
Practice Address - Street 1:600 S CONROE MEDICAL DR STE 102
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-5341
Practice Address - Country:US
Practice Address - Phone:936-539-4031
Practice Address - Fax:936-539-4537
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9832174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BK450OtherBCBS
TX00Z8364OtherMEDICARE GROUP
TX171710003Medicaid
TX203040501OtherMEDICAID GROUP
TX003RPOtherBCBS GROUP
TXH65185Medicare UPIN
TX8BK450OtherBCBS