Healthcare Provider Details

I. General information

NPI: 1548586977
Provider Name (Legal Business Name): OMOBONIKE OYINDASOLA OLORUNTOBA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MEDICINE CIRCLE
DURHAM NC
27710-3941
US

IV. Provider business mailing address

PO BOX 63362
CHARLOTTE NC
28263-3362
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-6437
  • Fax: 919-681-8147
Mailing address:
  • Phone: 919-684-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2014-00594
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number2014-00594
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number2014-00594
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2014-00594
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: