Provider Demographics
NPI:1902422785
Name:MICABY MEDICAL,PLLC
Entity Type:Organization
Organization Name:MICABY MEDICAL,PLLC
Other - Org Name:MICABY MEDICAL,PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HEZEKIAH
Authorized Official - Middle Name:OLUWAROTIMI
Authorized Official - Last Name:SOBAMOWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-397-0896
Mailing Address - Street 1:1222 MCCULLOUGH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4812
Mailing Address - Country:US
Mailing Address - Phone:210-858-7604
Mailing Address - Fax:210-888-0383
Practice Address - Street 1:10730 POTRANCO RD STE 122-507
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3327
Practice Address - Country:US
Practice Address - Phone:210-858-7604
Practice Address - Fax:210-888-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty