Provider Demographics
NPI:1841259421
Name:INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A.
Entity type:Organization
Organization Name:INTERNAL MEDICINE & INDUSTRIAL MEDICINE CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUBAYO
Authorized Official - Middle Name:AYOTUNDE
Authorized Official - Last Name:IDOWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-283-8777
Mailing Address - Street 1:2727 BOLTON BOONE DR
Mailing Address - Street 2:102
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2019
Mailing Address - Country:US
Mailing Address - Phone:972-283-8777
Mailing Address - Fax:972-283-9333
Practice Address - Street 1:2727 BOLTON BOONE DR
Practice Address - Street 2:102
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2019
Practice Address - Country:US
Practice Address - Phone:972-283-8777
Practice Address - Fax:972-283-9333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0033EVOtherBCBS
TX=========OtherEIN
TX8489M0/00225RMedicare ID - Type Unspecified
TX=========OtherEIN