Provider Demographics
NPI:1386804409
Name:FASAN, OMOTAYO OLUSOLA (MBBS)
Entity type:Individual
Prefix:DR
First Name:OMOTAYO
Middle Name:OLUSOLA
Last Name:FASAN
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 QUEENS RD STE 600
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3215
Practice Address - Country:US
Practice Address - Phone:980-302-6600
Practice Address - Fax:980-302-6605
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01292207R00000X, 207RH0000X
PAMD433151207R00000X, 207RH0000X
PAMT183411207R00000X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1838Medicaid
NC1386804409Medicaid
NCNCC861AMedicare PIN