Provider Demographics
NPI:1083111371
Name:O LONGEVITY & WELLNESS, PLLC
Entity Type:Organization
Organization Name:O LONGEVITY & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:SHADMAN
Authorized Official - Last Name:OTA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-365-8035
Mailing Address - Street 1:9821 N 95TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4589
Mailing Address - Country:US
Mailing Address - Phone:480-365-8035
Mailing Address - Fax:480-718-7373
Practice Address - Street 1:9821 N 95TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4589
Practice Address - Country:US
Practice Address - Phone:480-416-0403
Practice Address - Fax:480-240-5467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty