Provider Demographics
NPI:1104822097
Name:ADEBOGUN, OLADELE ADEPITAN (MD PA)
Entity Type:Individual
Prefix:DR
First Name:OLADELE
Middle Name:ADEPITAN
Last Name:ADEBOGUN
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2904 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2536
Mailing Address - Country:US
Mailing Address - Phone:870-773-4655
Mailing Address - Fax:870-772-4650
Practice Address - Street 1:2620 LONG PRAIRIE RD STE 100
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4953
Practice Address - Country:US
Practice Address - Phone:972-221-7900
Practice Address - Fax:972-221-7900
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN61282084A0401X, 2084P0800X
ARE-15992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116300726Medicaid
ARG74529Medicare UPIN
AR5K903Medicare PIN