Organization
DELTA MEDICAL PA
Active
Other names
DELTA MEDICAL CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
KOFOWOROLA EKADI M.D. (PRESIDENT)
(817) 412-8769
Entity
Organization
Contact information
Practice address
12001 SOUTH FWY, SUITE 210, BURLESON, TX 76028-7208
(817) 293-8797
Mailing address
PO BOX 93869, SOUTHLAKE, TX 76092-0118
(817) 293-8797
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
K9263
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00W561
MEDICARE
TX
01
—
P00053593
RAILROAD MEDICARE
TX
Enumeration date
05/31/2006
Last updated
04/08/2023
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