Healthcare Provider Details

I. General information

NPI: 1265254502
Provider Name (Legal Business Name): MOLAYO OTUBAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 SHELDON RD
CHANNELVIEW TX
77530-3512
US

IV. Provider business mailing address

12475 WOOD FOREST DR APT 1404
HOUSTON TX
77013-6124
US

V. Phone/Fax

Practice location:
  • Phone: 281-452-7184
  • Fax:
Mailing address:
  • Phone: 832-638-3142
  • 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: