Provider Demographics
NPI:1679744676
Name:OTINWA, BABATUNDE ADEBOLA (DO)
Entity type:Individual
Prefix:
First Name:BABATUNDE
Middle Name:ADEBOLA
Last Name:OTINWA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 FAIRBANKS N HOUSTON RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6306 FAIRBANKS N HOUSTON RD STE 500
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-5193
Practice Address - Country:US
Practice Address - Phone:832-831-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5306207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679744676OtherTRICARE SOUTH
TX8DH241OtherBCBS
TX284813708Medicaid
TX303109801Medicaid
TX284813707Medicaid
TX8DL678OtherBCBS
TXTXB166899Medicare PIN
TX284813708Medicaid
TX284813707Medicaid