Healthcare Provider Details

I. General information

NPI: 1790942308
Provider Name (Legal Business Name): OMOTAYO AYONIKE IDERA-ABDULLAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ANDREWS AVENUE
FORT RUCKER AL
36362-5333
US

IV. Provider business mailing address

301 ANDREWS AVE
FORT RUCKER AL
36362-5333
US

V. Phone/Fax

Practice location:
  • Phone: 344-255-7137
  • Fax:
Mailing address:
  • Phone: 334-255-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME119515
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: