Provider Demographics
NPI:1083298988
Name:KOLUREJO, OLUWADARE SAMSON
Entity Type:Individual
Prefix:
First Name:OLUWADARE
Middle Name:SAMSON
Last Name:KOLUREJO
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 1:2210 RUSTIC CHAPEL CT
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-2211
Mailing Address - Country:US
Mailing Address - Phone:832-759-4200
Mailing Address - Fax:
Practice Address - Street 1:2210 RUSTIC CHAPEL CT
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-2211
Practice Address - Country:US
Practice Address - Phone:832-759-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1351279225100000X
TX2161394225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX43674520OtherTEXAS ID
TX43674520OtherDRIVER LICENSE