Healthcare Provider Details

I. General information

NPI: 1902422785
Provider Name (Legal Business Name): MICABY MEDICAL,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 POTRANCO RD STE 122-507
SAN ANTONIO TX
78251-3327
US

IV. Provider business mailing address

1222 MCCULLOUGH AVE STE 101
SAN ANTONIO TX
78212-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-858-7604
  • Fax: 210-888-0383
Mailing address:
  • Phone: 210-858-7604
  • Fax: 210-888-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HEZEKIAH OLUWAROTIMI SOBAMOWO
Title or Position: PRESIDENT
Credential: MD
Phone: 615-397-0896