Healthcare Provider Details

I. General information

NPI: 1043496342
Provider Name (Legal Business Name): FORT MORGAN PEDIATRIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3564 DEER CREEK DR
MAUMEE OH
43537-8979
US

IV. Provider business mailing address

3564 DEER CREEK DR
MAUMEE OH
43537-8979
US

V. Phone/Fax

Practice location:
  • Phone: 530-355-3775
  • Fax:
Mailing address:
  • Phone: 530-355-3775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46228
License Number StateCO

VIII. Authorized Official

Name: DR. KEHINDE OBETO
Title or Position: PRESIDENT
Credential: MD
Phone: 213-926-3249