Provider Demographics
NPI:1255824355
Name:DAVID OMOBASUYI LLC
Entity Type:Organization
Organization Name:DAVID OMOBASUYI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OMOBASUYI
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, PMHNP-BC, DHSC
Authorized Official - Phone:305-898-7006
Mailing Address - Street 1:15716 SW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4271
Mailing Address - Country:US
Mailing Address - Phone:305-898-7006
Mailing Address - Fax:305-898-7006
Practice Address - Street 1:9701 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7015
Practice Address - Country:US
Practice Address - Phone:954-572-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2870242363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty