Basic Information
Provider Information | |||||||||
NPI: | 1235617267 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FATOBA | ||||||||
FirstName: | OLUGBENGA | ||||||||
MiddleName: | DANIEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6415 PINEWOOD HEIGHTS DR | ||||||||
Address2: |   | ||||||||
City: | SPRING | ||||||||
State: | TX | ||||||||
PostalCode: | 773895181 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9293323473 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2170 BUCKTHORNE PL STE 420 | ||||||||
Address2: |   | ||||||||
City: | SPRING | ||||||||
State: | TX | ||||||||
PostalCode: | 773801794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8324583793 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2018 | ||||||||
LastUpdateDate: | 08/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 941683 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   |
No ID Information.