Provider Demographics
NPI:1497913446
Name:OTUSANYA, SHIRLEY STOVALL
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:STOVALL
Last Name:OTUSANYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NE 213TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-1314
Mailing Address - Country:US
Mailing Address - Phone:305-652-0973
Mailing Address - Fax:
Practice Address - Street 1:1100 NE 213TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-1314
Practice Address - Country:US
Practice Address - Phone:305-652-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230408200Medicaid