Provider Demographics
NPI:1053163980
Name:OTIWU, STANLEY CHINONSO
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:CHINONSO
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:678-533-8784
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD293011835S0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835S0206XPharmacy Service ProvidersPharmacistSolid Organ Transplant