Provider Demographics
NPI:1770058125
Name:OLABODE, EMMANUEL ADEBO
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:ADEBO
Last Name:OLABODE
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 1:716 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-5243
Mailing Address - Country:US
Mailing Address - Phone:972-709-0309
Mailing Address - Fax:972-709-0309
Practice Address - Street 1:716 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-5243
Practice Address - Country:US
Practice Address - Phone:972-709-0309
Practice Address - Fax:972-709-0309
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0094092332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment