Provider Demographics
NPI:1750963104
Name:ETOMI, IBITORU EFUNSAMI
Entity type:Individual
Prefix:
First Name:IBITORU
Middle Name:EFUNSAMI
Last Name:ETOMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IBI
Other - Middle Name:EFUNSAMI
Other - Last Name:ETOMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5420 CALLANDER CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-5556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SLEEPY HOLLOW
Practice Address - State:NY
Practice Address - Zip Code:10591-1096
Practice Address - Country:US
Practice Address - Phone:914-366-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program