Provider Demographics
NPI:1265981872
Name:OMOTOYE, KAYODE EZEKIEL
Entity type:Individual
Prefix:MR
First Name:KAYODE
Middle Name:EZEKIEL
Last Name:OMOTOYE
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 1:11523 198TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2828
Mailing Address - Country:US
Mailing Address - Phone:917-480-8722
Mailing Address - Fax:
Practice Address - Street 1:11523 198TH ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2828
Practice Address - Country:US
Practice Address - Phone:917-480-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3257511164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse