Provider Demographics
NPI:1568673556
Name:ADEFEYISAN, SAMUEL ADEKUNLE (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADEKUNLE
Last Name:ADEFEYISAN
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 1:4314 CLAYTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3433
Mailing Address - Country:US
Mailing Address - Phone:214-708-9590
Mailing Address - Fax:
Practice Address - Street 1:4314 CLAYTON ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3433
Practice Address - Country:US
Practice Address - Phone:214-708-9590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83699207L00000X
ALMD.29707207L00000X, 2080P0203X
GA062934208000000X, 2080P0203X, 207L00000X
ALMD.2009208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine