Provider Demographics
NPI:1154514529
Name:OMOTOSO, OMOLOLA AJOKE (MD)
Entity type:Individual
Prefix:DR
First Name:OMOLOLA
Middle Name:AJOKE
Last Name:OMOTOSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1116
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461
Mailing Address - Country:US
Mailing Address - Phone:843-899-9099
Mailing Address - Fax:843-899-9091
Practice Address - Street 1:110 EXECUTIVE PARKWAY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-899-9099
Practice Address - Fax:843-899-9091
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT185765207R00000X
SC31061207R00000X
MO2016004893208M00000X
GA063694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist