Provider Demographics
NPI:1851647911
Name:KINGSWAY MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:KINGSWAY MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ADEKUNLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDEJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-601-2367
Mailing Address - Street 1:1030 N ZARAGOZA RD
Mailing Address - Street 2:SUITE X
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-1863
Mailing Address - Country:US
Mailing Address - Phone:915-881-4155
Mailing Address - Fax:915-881-4172
Practice Address - Street 1:1030 N ZARAGOZA RD
Practice Address - Street 2:SUITE X
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907-1863
Practice Address - Country:US
Practice Address - Phone:915-881-4155
Practice Address - Fax:915-881-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
TXN3416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3058117-01Medicaid