Provider Demographics
NPI:1902993686
Name:OLUWOLE, OLAWOLE SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:OLAWOLE
Middle Name:SAMUEL
Last Name:OLUWOLE
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 1:2201 MIDWAY RD
Mailing Address - Street 2:STE 112
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-5079
Mailing Address - Country:US
Mailing Address - Phone:972-829-0098
Mailing Address - Fax:972-436-0145
Practice Address - Street 1:13615 NEUTRON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-4411
Practice Address - Country:US
Practice Address - Phone:972-829-0098
Practice Address - Fax:972-436-0145
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180514501, 160177504Medicaid
TX180514501, 160177504Medicaid
TX00634Z, 8F1352Medicare PIN
TX113759318OtherTAX ID NUMBER