Provider Demographics
NPI:1942262316
Name:EKADI, KOFOWOROLA (MD)
Entity Type:Individual
Prefix:DR
First Name:KOFOWOROLA
Middle Name:
Last Name:EKADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KOFOWROLA
Other - Middle Name:
Other - Last Name:FALOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 93869
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0118
Mailing Address - Country:US
Mailing Address - Phone:817-293-8797
Mailing Address - Fax:817-293-8793
Practice Address - Street 1:12001 SOUTH FWY
Practice Address - Street 2:STE 210
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7208
Practice Address - Country:US
Practice Address - Phone:817-293-8797
Practice Address - Fax:817-293-8793
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
TXK9263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060392367Medicaid
P00053593OtherRAILROAD MEDICARE
TX060392367Medicaid
P00053593OtherRAILROAD MEDICARE