Provider Demographics
NPI:1083029060
Name:SHOBOWALE, EJODAMEN BLESSING (DPM)
Entity Type:Individual
Prefix:
First Name:EJODAMEN
Middle Name:BLESSING
Last Name:SHOBOWALE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:EJODAMEN
Other - Middle Name:B
Other - Last Name:SHOBOWALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:15003 FM 529 RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-4375
Mailing Address - Country:US
Mailing Address - Phone:832-819-3511
Mailing Address - Fax:281-619-7998
Practice Address - Street 1:15003 FM 529 RD STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-4379
Practice Address - Country:US
Practice Address - Phone:832-415-1790
Practice Address - Fax:281-619-7998
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2288213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX375642104Medicaid
TX375642103Medicaid
TX375642107Medicaid
TX003VAAOtherBCBS TX
TX375642105Medicaid
TX375642102Medicaid
TX375642106Medicaid
TX375642101Medicaid