Provider Demographics
NPI:1134429509
Name:MESQUITE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:MESQUITE MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEWUMI
Authorized Official - Middle Name:ADEWALE
Authorized Official - Last Name:BAKARE
Authorized Official - Suffix:
Authorized Official - Credentials:DMS, PA
Authorized Official - Phone:214-660-8554
Mailing Address - Street 1:5115 N GALLOWAY AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-7535
Mailing Address - Country:US
Mailing Address - Phone:214-660-8554
Mailing Address - Fax:214-660-8634
Practice Address - Street 1:5115 N GALLOWAY AVE STE 203
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-7535
Practice Address - Country:US
Practice Address - Phone:214-660-8554
Practice Address - Fax:214-660-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0064207R00000X, 261Q00000X
TXPA06380363A00000X
TXPA06308363A00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283257801Medicaid
TXTXB125532OtherMEDICARE PART B
TXTXB125541Medicare PIN
TXTXB125546Medicare PIN