Provider Demographics
NPI:1205467537
Name:IRANLOYE, SAMUEL OLATUNDUN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OLATUNDUN
Last Name:IRANLOYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 VATICAN LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-4719
Mailing Address - Country:US
Mailing Address - Phone:214-333-3393
Mailing Address - Fax:214-333-0809
Practice Address - Street 1:2225 VATICAN LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-4719
Practice Address - Country:US
Practice Address - Phone:214-333-3393
Practice Address - Fax:214-333-0809
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144638363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP144638Medicaid