Provider Demographics
NPI:1124735212
Name:EJOBOTODO, OMONIGHO
Entity type:Individual
Prefix:
First Name:OMONIGHO
Middle Name:
Last Name:EJOBOTODO
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 1:7360 ARUBA LN APT B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-1110
Mailing Address - Country:US
Mailing Address - Phone:317-658-5764
Mailing Address - Fax:
Practice Address - Street 1:7360 ARUBA LN APT B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-1110
Practice Address - Country:US
Practice Address - Phone:317-658-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5400369113343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)