Provider Demographics
NPI:1518952142
Name:OBAITAN, ADEBOWALE ANSELM (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEBOWALE
Middle Name:ANSELM
Last Name:OBAITAN
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 1:1430 LUCKENBACH DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4632
Mailing Address - Country:US
Mailing Address - Phone:972-390-8133
Mailing Address - Fax:972-390-9258
Practice Address - Street 1:1430 LUCKENBACH DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4632
Practice Address - Country:US
Practice Address - Phone:972-390-8133
Practice Address - Fax:972-390-9258
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051994207P00000X
TXM6319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2211482626OtherTRICARE SOUTH
GA52025889003OtherBCBS
GA688786920CMedicaid
GA2211482626OtherTRICARE SOUTH
H51825Medicare UPIN