Provider Demographics
NPI:1063089092
Name:OTIWU, EZEOYIBO JUSTIN (DPT)
Entity type:Individual
Prefix:
First Name:EZEOYIBO
Middle Name:JUSTIN
Last Name:OTIWU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 BRADFORD WALK TRL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7840
Mailing Address - Country:US
Mailing Address - Phone:678-654-4622
Mailing Address - Fax:
Practice Address - Street 1:3205 DEANS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-4208
Practice Address - Country:US
Practice Address - Phone:762-222-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist