Provider Demographics
NPI:1952754806
Name:MEDBAK HEALTHCARE SERVICES, PLLC
Entity Type:Organization
Organization Name:MEDBAK HEALTHCARE SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADEWUMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKARE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:214-516-1495
Mailing Address - Street 1:1130 BEACHVIEW ST
Mailing Address - Street 2:STE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3700
Mailing Address - Country:US
Mailing Address - Phone:214-516-1495
Mailing Address - Fax:
Practice Address - Street 1:1130 BEACHVIEW ST
Practice Address - Street 2:STE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3700
Practice Address - Country:US
Practice Address - Phone:214-516-1495
Practice Address - Fax:214-660-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06380363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty