Provider Demographics
NPI:1891392940
Name:DR OMOLOLA OMISHORE PT, P.C.
Entity type:Organization
Organization Name:DR OMOLOLA OMISHORE PT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OMOLOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OMISHORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-319-2245
Mailing Address - Street 1:1138 OCEAN AVE APT 6I
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230
Mailing Address - Country:US
Mailing Address - Phone:917-319-2245
Mailing Address - Fax:
Practice Address - Street 1:1138 OCEAN AVE APT 6I
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:917-319-2245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty