Healthcare Provider Details

I. General information

NPI: 1851889307
Provider Name (Legal Business Name): ALEXANDER OTAKPOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 MAGNOLIA AVE STE 202
CORONA CA
92879-3144
US

IV. Provider business mailing address

21600 OXNARD ST
WOODLAND HILLS CA
91367-4976
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-2020
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-11499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: