Basic Information
| Provider Information | |||||||||
| NPI: | 1205141884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOBAMOWO | ||||||||
| FirstName: | HEZEKIAH | ||||||||
| MiddleName: | OLUWAROTIMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706015724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374338400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10730 POTRANCO RD STE 122-507 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782513327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374338400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2010 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 204750 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | FR0435669053 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | MD.204750 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RN0300X | P1595 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 2159658 | 05 | LA | MEDICAID | 08770558 | 05 | MS | MEDICAID |