Provider Demographics
NPI:1417268376
Name:ODEYEMI, ADETUNJI A
Entity Type:Individual
Prefix:
First Name:ADETUNJI
Middle Name:A
Last Name:ODEYEMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E LAMAR BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-7346
Mailing Address - Country:US
Mailing Address - Phone:817-861-3994
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAMAR BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-7346
Practice Address - Country:US
Practice Address - Phone:817-861-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2014-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000802367500000X
TX728692367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered