MEDICARE: FOLASHADE OMOLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	049074	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841290707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FOLASHADE OMOLE MD

Provider Business Mailing Address
First Line	:	720 WESTVIEW DR SW STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1458
Country	:	US
Telephone Number	:	404-756-1400
Fax Number	:	404-756-5274

Provider Business Practice Location Address
First Line	:	1513 CLEVELAND AVE
Second Line	:	BLDG 500
City	:	EAST POINT
State	:	GA
Zip	:	30344-6947
Country	:	US
Telephone Number	:	404-756-1205
Fax Number	:	404-756-1229

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	05/10/2019

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Directions to “ FOLASHADE OMOLE MD” Practice Location

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