Provider Demographics
NPI:1477541621
Name:OTAH, ESEROGHENE (MD)
Entity Type:Individual
Prefix:DR
First Name:ESEROGHENE
Middle Name:
Last Name:OTAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ESE
Other - Middle Name:
Other - Last Name:OTAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:138 ELDRIDGE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4083
Mailing Address - Country:US
Mailing Address - Phone:281-232-3886
Mailing Address - Fax:281-232-3986
Practice Address - Street 1:138 ELDRIDGE RD
Practice Address - Street 2:SUITE E
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4083
Practice Address - Country:US
Practice Address - Phone:281-232-3886
Practice Address - Fax:281-232-3986
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6554208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1663841Medicaid
TX1703076Medicaid
TX1703076Medicaid
H79997Medicare UPIN