Provider Demographics
NPI:1679546972
Name:OSIBAMOWO, ABIODUN (MD)
Entity Type:Individual
Prefix:
First Name:ABIODUN
Middle Name:
Last Name:OSIBAMOWO
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 1:11910 GREENVILLE AVE
Mailing Address - Street 2:#500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3596
Mailing Address - Country:US
Mailing Address - Phone:214-572-1124
Mailing Address - Fax:214-572-7724
Practice Address - Street 1:11888 MARSH LN
Practice Address - Street 2:#104
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-8083
Practice Address - Country:US
Practice Address - Phone:972-488-9222
Practice Address - Fax:972-488-0625
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7366207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8616M9Medicare ID - Type Unspecified
TXG85830Medicare UPIN