Provider Demographics
NPI:1871842161
Name:DARAMOLA, OLUBUSOLA TEMIDAYO
Entity Type:Individual
Prefix:MRS
First Name:OLUBUSOLA
Middle Name:TEMIDAYO
Last Name:DARAMOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 S HULEN ST
Mailing Address - Street 2:SUITE 360 PMB 229
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2622
Mailing Address - Country:US
Mailing Address - Phone:864-426-2306
Mailing Address - Fax:
Practice Address - Street 1:206 WALLS DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4045
Practice Address - Country:US
Practice Address - Phone:817-645-0668
Practice Address - Fax:817-645-0720
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-03
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX824556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDO7564OtherRR GROUP
TXP01111340OtherRR MEDICARE PTAN
TX2035487-04Medicaid
TX3089625-01Medicaid
TX890N47OtherBCBS PTAN
TX890N47OtherBCBS PTAN
TXTXB166548Medicare PIN