Provider Demographics
NPI:1467427054
Name:ADEDOKUN, ADE LATEEF (DO)
Entity Type:Individual
Prefix:MR
First Name:ADE
Middle Name:LATEEF
Last Name:ADEDOKUN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:817-378-3699
Practice Address - Street 1:6116 OAKBEND TRL STE 112
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3926
Practice Address - Country:US
Practice Address - Phone:817-423-9054
Practice Address - Fax:817-423-9719
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5755204R00000X, 2081S0010X, 208VP0000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX250010812Medicare PIN
TX00740XMedicare ID - Type Unspecified
G70062Medicare UPIN
TX8C9384Medicare PIN
TX00740XMedicare ID - Type Unspecified
TX096709302Medicaid
TX0033DVOtherBCBS
G70062Medicare UPIN
TX8C9384Medicare PIN