Provider Demographics
NPI:1699778894
Name:AWOMOLO, ADESOLA (MD)
Entity type:Individual
Prefix:
First Name:ADESOLA
Middle Name:
Last Name:AWOMOLO
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 1:3555 10TH CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-567-4673
Practice Address - Fax:772-400-6932
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101004207RX0202X
IN01083014A207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC830008545OtherPALMETO GBA-RAILROAD MEDI
NC891292UMedicaid
NC1292UOtherBLUE CROSS / BLUE SHIELD
SCQ0100OMedicaid
SCQ0100OMedicaid
NC830008545OtherPALMETO GBA-RAILROAD MEDI
NCG78434Medicare UPIN