Provider Demographics
NPI:1598147811
Name:ADEAGBO, COLLINS
Entity Type:Individual
Prefix:
First Name:COLLINS
Middle Name:
Last Name:ADEAGBO
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 1:207 BALSAM GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-5361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 BALSAM GROVE CIR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-5361
Practice Address - Country:US
Practice Address - Phone:469-463-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2556790246Z00000X
TX2355690247000000X
TX255690251E00000X
251K00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
No251K00000XAgenciesPublic Health or Welfare
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service