Provider Demographics
NPI:1457626848
Name:OTIWU, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:OTIWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 BRADFORD WALK TRL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7840
Mailing Address - Country:US
Mailing Address - Phone:770-355-4114
Mailing Address - Fax:
Practice Address - Street 1:3965 BRADFORD WALK TRL
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-7840
Practice Address - Country:US
Practice Address - Phone:770-355-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-0704374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide