Basic Information
| Provider Information | |||||||||
| NPI: | 1104822097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADEBOGUN | ||||||||
| FirstName: | OLADELE | ||||||||
| MiddleName: | ADEPITAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD. PA. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2904 ARKANSAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707734655 | ||||||||
| FaxNumber: | 8707724650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 LONG PRAIRIE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750224953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722217900 | ||||||||
| FaxNumber: | 9722217900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | N6128 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | E-1599 | AR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | N6128 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 116300726 | 05 | TX | MEDICAID |