Healthcare Provider Details

I. General information

NPI: 1356159917
Provider Name (Legal Business Name): OLUWATOBI GBADAMOSI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6941 LILAC DR
VENUS TX
76084-3656
US

IV. Provider business mailing address

6941 LILAC DR
VENUS TX
76084-3656
US

V. Phone/Fax

Practice location:
  • Phone: 443-929-5355
  • Fax:
Mailing address:
  • Phone: 443-929-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number50583156
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: