Healthcare Provider Details

I. General information

NPI: 1568555258
Provider Name (Legal Business Name): TOLA B FASHOKUN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TOLA B OMOTOSHO M.D.

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 W BELVEDERE AVE
BALTIMORE MD
21215-5228
US

IV. Provider business mailing address

PO BOX 64313
BALTIMORE MD
21264-4313
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-2523
  • Fax: 410-601-2524
Mailing address:
  • Phone: 410-550-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD60686
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD2006-0148
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberD60686
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: