Provider Demographics
NPI:1780028951
Name:FADAHUNSI, ANGELA WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:WALLACE
Last Name:FADAHUNSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:LATRESHA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:611 S HIGHWAY 78 STE 102
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4085
Mailing Address - Country:US
Mailing Address - Phone:972-954-9826
Mailing Address - Fax:
Practice Address - Street 1:611 S HIGHWAY 78 STE 102
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098
Practice Address - Country:US
Practice Address - Phone:972-954-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5721207R00000X, 207K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program