Provider Demographics
NPI:1396833125
Name:BENEDICT OLUSOLA MD PA
Entity Type:Organization
Organization Name:BENEDICT OLUSOLA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARVELLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:972-228-3677
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8302
Mailing Address - Country:US
Mailing Address - Phone:972-228-3677
Mailing Address - Fax:972-228-3672
Practice Address - Street 1:1700 N HAMPTON RD
Practice Address - Street 2:STE 100
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2392
Practice Address - Country:US
Practice Address - Phone:972-228-3677
Practice Address - Fax:972-228-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00804ZMedicare PIN