Provider Demographics
NPI:1063713832
Name:OWOT, OWOT ETIM
Entity type:Individual
Prefix:MR
First Name:OWOT
Middle Name:ETIM
Last Name:OWOT
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 1:4501 ROWLETT RD STE 104
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-5093
Mailing Address - Country:US
Mailing Address - Phone:214-607-4027
Mailing Address - Fax:214-607-4028
Practice Address - Street 1:4501 ROWLETT RD STE 104
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-5093
Practice Address - Country:US
Practice Address - Phone:214-607-4027
Practice Address - Fax:214-607-4028
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX011070251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicare Oscar/Certification