Provider Demographics
NPI:1275945396
Name:IMOISILI, OMOYE ENISEGHO (MD, MPH)
Entity Type:Individual
Prefix:
First Name:OMOYE
Middle Name:ENISEGHO
Last Name:IMOISILI
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PONCE DE LEON AVE
Mailing Address - Street 2:APARTMENT 282
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 HARRY S TRUMAN DR N
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5477
Practice Address - Country:US
Practice Address - Phone:240-677-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD86819207R00000X, 208M00000X
GA77676207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program