Provider Demographics
NPI:1306050877
Name:OMOTOSHO, PHILIP A (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:OMOTOSHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ERWIN RD
Mailing Address - Street 2:DUMC BOX 2830
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710
Mailing Address - Country:US
Mailing Address - Phone:919-681-3882
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:DUMC BOX 2830
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710
Practice Address - Country:US
Practice Address - Phone:919-681-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01486208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery