Provider Demographics
NPI:1013995810
Name:DARAMOLA, JOHN BAMIDELE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BAMIDELE
Last Name:DARAMOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 S HULEN ST
Mailing Address - Street 2:STE 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:817-556-0201
Mailing Address - Fax:817-556-0213
Practice Address - Street 1:505 N RIDGEWAY DR
Practice Address - Street 2:SUITE 282
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-5118
Practice Address - Country:US
Practice Address - Phone:817-556-0201
Practice Address - Fax:817-556-0213
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4369207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC231519Medicaid
SCP00365956OtherMEDICARE RRGA
SCP00365956OtherMEDICARE RRGA
SCH633588165Medicare PIN
SCH633589342Medicare PIN
SC231519Medicaid