Provider Demographics
NPI:1235496845
Name:OMOTOSHO, MOBOLAJI JOHNSON (DPT)
Entity Type:Individual
Prefix:
First Name:MOBOLAJI
Middle Name:JOHNSON
Last Name:OMOTOSHO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 PELLICANO DR
Mailing Address - Street 2:APT 112
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6835
Mailing Address - Country:US
Mailing Address - Phone:915-861-9977
Mailing Address - Fax:
Practice Address - Street 1:6028 SURETY DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2024
Practice Address - Country:US
Practice Address - Phone:915-771-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1216728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX92262701Medicaid
TX310252YNCDOtherMEDICARE PTAN THERAPY CONSULTANTS
TX310252YNCDOtherMEDICARE PTAN THERAPY CONSULTANTS