Healthcare Provider Details

I. General information

NPI: 1285612648
Provider Name (Legal Business Name): FABIO MOTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

1921 STONECIPHER BOULEVARD
ADA OK
74820-3439
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-4570
  • Fax: 580-272-2715
Mailing address:
  • Phone: 580-421-4584
  • Fax: 580-421-6224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35039116M
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: