Provider Demographics
NPI:1679398978
Name:GORDON, OMOBOLA
Entity type:Individual
Prefix:
First Name:OMOBOLA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8925 E HIGHWAY 20 TRLR 89
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-1794
Mailing Address - Country:US
Mailing Address - Phone:281-948-6565
Mailing Address - Fax:
Practice Address - Street 1:8925 E HIGHWAY 20 TRLR 89
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-1794
Practice Address - Country:US
Practice Address - Phone:281-948-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator