Healthcare Provider Details

I. General information

NPI: 1366389140
Provider Name (Legal Business Name): OMOWUNMI RACHAEL ADEWARA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MINNEQUA AVENUE, SOUTHERN COLORADO FAMILY MEDICINE MEDICAL ARTS BUILDING, SUITE 115
PUEBLE CO
81004
US

IV. Provider business mailing address

902 LAKEVIEW AVENUE,
PUEBLO CO
81004
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-5855
  • Fax: 719-557-5097
Mailing address:
  • Phone: 719-557-5855
  • Fax: 719-557-5097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTL.0011430
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: