Provider Demographics
NPI:1740343177
Name:MICHAEL E ESEDEBE MDPA
Entity type:Organization
Organization Name:MICHAEL E ESEDEBE MDPA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EMEKA
Authorized Official - Last Name:ESEDEBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-336-9559
Mailing Address - Street 1:11617 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 240
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3800
Mailing Address - Country:US
Mailing Address - Phone:214-553-1516
Mailing Address - Fax:214-553-1519
Practice Address - Street 1:11617 N CENTRAL EXPY
Practice Address - Street 2:SUITE 240
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3800
Practice Address - Country:US
Practice Address - Phone:214-553-1516
Practice Address - Fax:214-553-1519
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL E ESEDEBE MDPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-18
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0155261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047474404Medicaid
TX047474404Medicaid