Provider Demographics
NPI:1891818399
Name:IDOWU, OLUBAYO A (MD)
Entity Type:Individual
Prefix:
First Name:OLUBAYO
Middle Name:A
Last Name:IDOWU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 BOLTON BOONE DR
Mailing Address - Street 2:#102
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2019
Mailing Address - Country:US
Mailing Address - Phone:972-283-8777
Mailing Address - Fax:972-283-9333
Practice Address - Street 1:2727 BOLTON BOONE DR
Practice Address - Street 2:#102
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2019
Practice Address - Country:US
Practice Address - Phone:972-283-8777
Practice Address - Fax:972-283-9333
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK06009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111880404Medicaid
TXK06009OtherLICENCE
TX111880404Medicaid
TXK06009OtherLICENCE