Provider Demographics
NPI:1083009484
Name:OTABIL, MAAME EFUA SOMPA (MD)
Entity Type:Individual
Prefix:
First Name:MAAME EFUA
Middle Name:SOMPA
Last Name:OTABIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAAME EFUA
Other - Middle Name:SOMPA
Other - Last Name:OTABIL-NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2716 W REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3901
Mailing Address - Country:US
Mailing Address - Phone:417-881-8812
Mailing Address - Fax:
Practice Address - Street 1:2716 W REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3901
Practice Address - Country:US
Practice Address - Phone:417-881-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2018034807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program