Healthcare Provider Details

I. General information

NPI: 1871875344
Provider Name (Legal Business Name): OMONIYI OMOTOSO M.D., M.P.H., FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 06/06/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 INTERNATIONAL BLVD
OAKLAND CA
94601-2228
US

IV. Provider business mailing address

2920 INTERNATIONAL BOULEVARD NATIVE AMERICAN HEALTH CENTER - ADMINISTRATIVE OFFICE
OAKLAND CA
94611
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4400
  • Fax: 510-535-8474
Mailing address:
  • Phone: 510-535-4400
  • Fax: 510-535-8474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: