Healthcare Provider Details

I. General information

NPI: 1568267706
Provider Name (Legal Business Name): ISAAC OBODO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3864 VILLAFLORA DR APT 5307
FORT WORTH TX
76137-7146
US

IV. Provider business mailing address

3864 VILLAFLORA DR APT 5307
FORT WORTH TX
76137-7146
US

V. Phone/Fax

Practice location:
  • Phone: 925-895-6840
  • Fax:
Mailing address:
  • Phone: 925-895-6840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: