Provider Demographics
NPI:1932696275
Name:OLUSOGA, KEHINDE
Entity Type:Individual
Prefix:
First Name:KEHINDE
Middle Name:
Last Name:OLUSOGA
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 1:4004 GREENWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5560
Mailing Address - Country:US
Mailing Address - Phone:817-714-9823
Mailing Address - Fax:
Practice Address - Street 1:4004 GREENWOOD WAY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5560
Practice Address - Country:US
Practice Address - Phone:817-714-9823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX261QM0850XMedicaid