Provider Demographics
NPI:1124630496
Name:ASEMOTA, EDOBA
Entity type:Individual
Prefix:
First Name:EDOBA
Middle Name:
Last Name:ASEMOTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDOBA
Other - Middle Name:
Other - Last Name:ASEMOTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2019 LOS FELIZ DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3070
Mailing Address - Country:US
Mailing Address - Phone:805-341-1073
Mailing Address - Fax:
Practice Address - Street 1:2019 LOS FELIZ DR
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-3070
Practice Address - Country:US
Practice Address - Phone:805-341-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6116572347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle