Healthcare Provider Details

I. General information

NPI: 1306694864
Provider Name (Legal Business Name): GIFTTY ESEOISA OBADAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 CITY AVE
PHILADELPHIA PA
19131-1626
US

IV. Provider business mailing address

6423 LANDOVER RD APT T3
CHEVERLY MD
20785-1413
US

V. Phone/Fax

Practice location:
  • Phone: 215-871-6694
  • Fax:
Mailing address:
  • Phone: 832-468-4579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: