Healthcare Provider Details

I. General information

NPI: 1609429406
Provider Name (Legal Business Name): OMOLARA GRACE ADENIRAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2019
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 BRANDON MAIN ST STE D
BRANDON FL
33511-5018
US

IV. Provider business mailing address

38135 MARKET SQUARE DR
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 813-977-2020
  • Fax: 813-355-5010
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number445764
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME1683456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: