Provider Demographics
NPI:1023122371
Name:ADESOBA, SAMUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:ADESOBA
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:P.O. BOX 711047
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77271
Mailing Address - Country:US
Mailing Address - Phone:713-962-4055
Mailing Address - Fax:713-962-4055
Practice Address - Street 1:9639 FONDREN ROAD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096
Practice Address - Country:US
Practice Address - Phone:713-962-4055
Practice Address - Fax:713-962-4055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7235207R00000X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138035423Medicaid
TX138035423Medicaid