Provider Demographics
NPI:1174374508
Name:OTABOR, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:OTABOR
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 1:32035 BRILLIANT SUN CT
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-2634
Mailing Address - Country:US
Mailing Address - Phone:347-859-0266
Mailing Address - Fax:
Practice Address - Street 1:32035 BRILLIANT SUN CT
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-2634
Practice Address - Country:US
Practice Address - Phone:347-859-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide