Provider Demographics
NPI:1831484062
Name:OMOTAYO, BABAJIDE
Entity Type:Individual
Prefix:
First Name:BABAJIDE
Middle Name:
Last Name:OMOTAYO
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:PO BOX 720715
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77272-0715
Mailing Address - Country:US
Mailing Address - Phone:409-499-3796
Mailing Address - Fax:
Practice Address - Street 1:10300 S WILCREST DR
Practice Address - Street 2:#309
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-2867
Practice Address - Country:US
Practice Address - Phone:409-499-3796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226313164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse