Provider Demographics
NPI:1770530586
Name:BADA, SAMUEL OLANIYI (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OLANIYI
Last Name:BADA
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 1:1673 N ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3607
Mailing Address - Country:US
Mailing Address - Phone:731-265-1997
Mailing Address - Fax:731-265-0511
Practice Address - Street 1:1673 N ROYAL ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3607
Practice Address - Country:US
Practice Address - Phone:731-265-1997
Practice Address - Fax:731-265-0511
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3833490Medicaid
TN3858256Medicaid
TN3833490Medicaid
TN3858256Medicaid
TN38582501Medicare PIN
TN3858256Medicare PIN