Healthcare Provider Details

I. General information

NPI: 1467192039
Provider Name (Legal Business Name): OMOLOLU LONGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4143 JOHN F KENNEDY BLVD
NORTH LITTLE ROCK AR
72116-8264
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 600
NASHVILLE TN
37205-5250
US

V. Phone/Fax

Practice location:
  • Phone: 501-307-7643
  • Fax: 855-576-4813
Mailing address:
  • Phone: 888-987-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-20445
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: