Provider Demographics
NPI:1841274578
Name:AMUSAN, ADEOLA A (MD)
Entity type:Individual
Prefix:
First Name:ADEOLA
Middle Name:A
Last Name:AMUSAN
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9202 ELAM RD
Practice Address - Street 2:SOUTHEAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4151
Practice Address - Country:US
Practice Address - Phone:214-266-1600
Practice Address - Fax:214-266-1790
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148738108Medicaid
TX148738105Medicaid
TX148738119Medicaid
TX148738110Medicaid
TX148738113Medicaid
TX148738114Medicaid
TX148738106Medicaid
TX148738109Medicaid
TX148738111Medicaid
TX148738116Medicaid
TX148738117Medicaid
TX8U3653OtherBLUE CROSS BLUE SHIELD
TX148738115Medicaid
TX148738106Medicaid
TX8B7990Medicare PIN