Provider Demographics
NPI:1285612648
Name:MOTA, FABIO (MD)
Entity type:Individual
Prefix:
First Name:FABIO
Middle Name:
Last Name:MOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:580-421-4584
Mailing Address - Fax:580-421-6224
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-421-4570
Practice Address - Fax:580-272-2715
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35039116M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKA82065Medicare UPIN