Provider Demographics
NPI: | 1922078120 |
---|---|
Name: | AKIODE, OLADIMEJI SAMSON (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | OLADIMEJI |
Middle Name: | SAMSON |
Last Name: | AKIODE |
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: | PO BOX 742616 |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30374-2616 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 770-219-9000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 800 E DAWSON ST |
Practice Address - Street 2: | |
Practice Address - City: | TYLER |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75701-2036 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-510-1186 |
Practice Address - Fax: | 903-585-1254 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-01-23 |
Last Update Date: | 2021-01-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | L5220 | 207R00000X |
GA | 047876 | 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 165951801 | Medicaid | |
TX | 1F7735 | Other | MEDICARE |
TN | H80034 | Medicare UPIN | |
TN | 8C0350 | Medicare ID - Type Unspecified | MEDICARE |