Provider Demographics
NPI:1376752048
Name:KOMOLAFE, BABATUNDE O (MD)
Entity Type:Individual
Prefix:DR
First Name:BABATUNDE
Middle Name:O
Last Name:KOMOLAFE
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 1:2800 E BROAD ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6411
Mailing Address - Country:US
Mailing Address - Phone:817-752-5242
Mailing Address - Fax:817-752-5232
Practice Address - Street 1:2800 E BROAD ST STE 204
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6411
Practice Address - Country:US
Practice Address - Phone:817-752-5242
Practice Address - Fax:817-752-5232
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL33580174400000X
390200000X
TXQ0486207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL165521Medicaid
TX407447803Medicaid