Provider Demographics
NPI:1275262057
Name:MESQUITE MEDICAL CLINIC
Entity Type:Organization
Organization Name:MESQUITE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADEWUMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKARE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:214-516-1495
Mailing Address - Street 1:5115 N GALLOWAY AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7535
Mailing Address - Country:US
Mailing Address - Phone:214-660-8554
Mailing Address - Fax:214-660-8634
Practice Address - Street 1:5115 N GALLOWAY AVE STE 203
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-7535
Practice Address - Country:US
Practice Address - Phone:214-660-8554
Practice Address - Fax:214-660-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty