Healthcare Provider Details

I. General information

NPI: 1013406818
Provider Name (Legal Business Name): ADEOLA AWOMOLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 11/03/2021
Certification Date: 10/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON ST
NEW BRUNSWICK NJ
08901-1962
US

IV. Provider business mailing address

9180 PINECROFT DR
SHENANDOAH TX
77380-2794
US

V. Phone/Fax

Practice location:
  • Phone: 718-909-4661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberT0166
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA96140107462882
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: