Provider Demographics
NPI:1992486591
Name:OTIWU, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:OTIWU
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 1:3965 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:678-488-1093
Mailing Address - Fax:
Practice Address - Street 1:3965 BRADFORD WALK TRL
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-7840
Practice Address - Country:US
Practice Address - Phone:678-488-1093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN283773163W00000X
GA148574367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse