Healthcare Provider Details

I. General information

NPI: 1841290707
Provider Name (Legal Business Name): FOLASHADE OMOLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 CLEVELAND AVE BLDG 500
EAST POINT GA
30344-6947
US

IV. Provider business mailing address

720 WESTVIEW DR SW STE 100
ATLANTA GA
30310-1458
US

V. Phone/Fax

Practice location:
  • Phone: 404-756-1205
  • Fax: 404-756-1229
Mailing address:
  • Phone: 404-756-1400
  • Fax: 404-756-5274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049074
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: