Healthcare Provider Details

I. General information

NPI: 1528164324
Provider Name (Legal Business Name): OMODELE JULIE MASHA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 BROOKDALE DR
STATESVILLE NC
28677-4108
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-872-9595
  • Fax:
Mailing address:
  • Phone: 704-874-0567
  • Fax: 704-874-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009-01717
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009-01717
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-01717
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: