Provider Demographics
NPI:1700054665
Name:TIJANI, ADISA A
Entity Type:Individual
Prefix:
First Name:ADISA
Middle Name:A
Last Name:TIJANI
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:PO BOX 741411
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9319 LBJ FWY
Practice Address - Street 2:STE 208G
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3450
Practice Address - Country:US
Practice Address - Phone:214-575-0666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0066978332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173760303Medicaid
TX173760301Medicaid
TX531586OtherBLUE CROSS BLUE SHIELD
LA1628794Medicaid
TX173760302Medicaid
TX173760302Medicaid