Provider Demographics
NPI:1417078411
Name:OLADELE OLUSANYA MD PA
Entity Type:Organization
Organization Name:OLADELE OLUSANYA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLADELE
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLUSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-230-5601
Mailing Address - Street 1:8067 WEST VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3767
Mailing Address - Country:US
Mailing Address - Phone:972-230-5601
Mailing Address - Fax:972-230-5591
Practice Address - Street 1:8067 WEST VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3767
Practice Address - Country:US
Practice Address - Phone:972-230-5601
Practice Address - Fax:972-230-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153097402OtherMEDICAID THSTEPS
TX153097401Medicaid
TX00867TMedicare ID - Type Unspecified
TX153097401Medicaid