Provider Demographics
NPI:1205848785
Name:OMOTOSO, IRENE A (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:A
Last Name:OMOTOSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IRENE
Other - Middle Name:AYOYINKA
Other - Last Name:ALFONSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:112 GOVERNORS SQ STE B
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4864
Mailing Address - Country:US
Mailing Address - Phone:678-932-8112
Mailing Address - Fax:678-932-8113
Practice Address - Street 1:112 GOVERNORS SQ STE B
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4864
Practice Address - Country:US
Practice Address - Phone:678-932-8112
Practice Address - Fax:678-932-8113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053629208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH91558Medicare UPIN
GA511I110532Medicare PIN