Provider Demographics
NPI:1851432462
Name:FORT WORTH INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:FORT WORTH INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEBOLA
Authorized Official - Middle Name:SULAIMAN
Authorized Official - Last Name:OLATUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-386-9818
Mailing Address - Street 1:654 SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3358
Mailing Address - Country:US
Mailing Address - Phone:817-386-9818
Mailing Address - Fax:
Practice Address - Street 1:654 SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3358
Practice Address - Country:US
Practice Address - Phone:817-386-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty