Provider Demographics
NPI:1518191493
Name:GOMES, OLUBUSOLA (MD)
Entity type:Individual
Prefix:
First Name:OLUBUSOLA
Middle Name:
Last Name:GOMES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 ELIZABETH AVE STE 5-383
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5110
Mailing Address - Country:US
Mailing Address - Phone:908-340-0027
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 N STE 104
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:908-340-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58764207R00000X, 207RS0012X
VA0101262025207RS0012X
390200000X
NJ25MA08986700207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1518191493Medicaid