Provider Demographics
NPI:1700209608
Name:OBANOYEN, OLUWASEYI
Entity Type:Individual
Prefix:
First Name:OLUWASEYI
Middle Name:
Last Name:OBANOYEN
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 1:23225 KINGSLAND BLVD
Mailing Address - Street 2:STE 600
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-3705
Mailing Address - Country:US
Mailing Address - Phone:682-730-0004
Mailing Address - Fax:
Practice Address - Street 1:101 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2618
Practice Address - Country:US
Practice Address - Phone:682-730-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1237597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist