Healthcare Provider Details

I. General information

NPI: 1528755741
Provider Name (Legal Business Name): DEBORAH DAMILOLA OMOLEYE M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. DEBORAH OLUWADAMILOLA FASOGBON

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 08/28/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LENOX AVENUE
NEW YORK NY
10037
US

IV. Provider business mailing address

40 W 135TH STREET APR 09B
NEW YORK NY
10037
US

V. Phone/Fax

Practice location:
  • Phone: 212-939-4019
  • Fax: 212-939-4022
Mailing address:
  • Phone: 347-736-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: