Provider Demographics
NPI:1841519618
Name:COLADOM MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:COLADOM MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KOLAWOLE
Authorized Official - Middle Name:ADEMUYIWA
Authorized Official - Last Name:ODULAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-455-0074
Mailing Address - Street 1:510 MED CT
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3482
Mailing Address - Country:US
Mailing Address - Phone:210-455-0074
Mailing Address - Fax:210-455-0124
Practice Address - Street 1:510 MED CT
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3482
Practice Address - Country:US
Practice Address - Phone:210-455-0074
Practice Address - Fax:210-455-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217153001Medicaid
0008TNOtherBLUE CROSS BLUE SHIELD OF TEXAS
TXB104603Medicare PIN