Provider Demographics
NPI:1356654909
Name:ODUMOSU, OLUWASEUN (MD)
Entity Type:Individual
Prefix:
First Name:OLUWASEUN
Middle Name:
Last Name:ODUMOSU
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 1:420 JOHNSON RD STE 304
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3463
Mailing Address - Country:US
Mailing Address - Phone:817-710-3040
Mailing Address - Fax:989-200-4650
Practice Address - Street 1:420 JOHNSON RD STE 304
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3463
Practice Address - Country:US
Practice Address - Phone:817-710-3040
Practice Address - Fax:989-200-4650
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5786207Q00000X
PAMT197589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine