Provider Demographics
NPI:1417120395
Name:OLATINWO, OMOTAYO MUTIAT (MD)
Entity Type:Individual
Prefix:DR
First Name:OMOTAYO
Middle Name:MUTIAT
Last Name:OLATINWO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OMOTAYO
Other - Middle Name:MUTIAT
Other - Last Name:OLARINOYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:ALEXANDRIA VA HEALTH CARE SYSTEM
Mailing Address - Street 2:2495 SHREVEPORT HIGHWAY
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:ALEXANDRIA VA HEALTH CARE SYSTEM
Practice Address - Street 2:2495 SHREVEPORT HIGHWAY
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063279207RG0300X
LAMD.204261207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2160818Medicaid
LA4P878Medicare PIN