Provider Demographics
NPI:1093750531
Name:OLOFINLADE, OLUSOLA (MD)
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:
Last Name:OLOFINLADE
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 1:701 E MARSHALL AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5573
Mailing Address - Country:US
Mailing Address - Phone:903-236-2222
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL AVE
Practice Address - Street 2:STE. 200
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5573
Practice Address - Country:US
Practice Address - Phone:903-236-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2520207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145747502Medicaid
H25173Medicare UPIN
TX145747502Medicaid