Basic Information
Provider Information | |||||||||
NPI: | 1457585739 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALMON | ||||||||
FirstName: | OLAYIWOLA | ||||||||
MiddleName: | ABDULLATEEF | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17407 ASTRACHAN RD | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | TX | ||||||||
PostalCode: | 774072703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8322746476 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7601 SOUTHCREST PKWY | ||||||||
Address2: |   | ||||||||
City: | SOUTHAVEN | ||||||||
State: | MS | ||||||||
PostalCode: | 386714739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6627722980 | ||||||||
FaxNumber: | 6627722960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2009 | ||||||||
LastUpdateDate: | 11/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N5991 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD.202977 | LA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 20974 | MS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.