Healthcare Provider Details

I. General information

NPI: 1992486591
Provider Name (Legal Business Name): BENJAMIN OTIWU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 BRADFORD WALK TRL
BUFORD GA
30519-7840
US

IV. Provider business mailing address

3965 BRADFORD WALK TRL
BUFORD GA
30519-7840
US

V. Phone/Fax

Practice location:
  • Phone: 678-488-1093
  • Fax:
Mailing address:
  • Phone: 678-488-1093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN283773
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148574
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: