Provider Demographics
NPI:1245509108
Name:ADEWALE, ADEBAYO (MD)
Entity type:Individual
Prefix:
First Name:ADEBAYO
Middle Name:
Last Name:ADEWALE
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 1:4002 S LOOP 256
Mailing Address - Street 2:STE F
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8493
Mailing Address - Country:US
Mailing Address - Phone:903-723-8210
Mailing Address - Fax:903-723-8310
Practice Address - Street 1:4002 S LOOP 256
Practice Address - Street 2:STE F
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8493
Practice Address - Country:US
Practice Address - Phone:903-723-8210
Practice Address - Fax:903-723-8310
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY267748207R00000X
TXQ0394207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370852YKKNCMedicare PIN