Healthcare Provider Details

I. General information

NPI: 1124505615
Provider Name (Legal Business Name): MICHAEL G OMOTOLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 BELT LINE RD STE 124
ADDISON TX
75001-5879
US

IV. Provider business mailing address

417 W 20TH ST UNIT 11386
NORFOLK VA
23517-1287
US

V. Phone/Fax

Practice location:
  • Phone: 469-495-9126
  • Fax: 469-495-0726
Mailing address:
  • Phone: 512-363-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12295
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: