Provider Demographics
NPI:1477669380
Name:OMOLARA, KHARI ABAYOMI (MD)
Entity Type:Individual
Prefix:MR
First Name:KHARI
Middle Name:ABAYOMI
Last Name:OMOLARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39603-7129
Mailing Address - Country:US
Mailing Address - Phone:601-445-1922
Mailing Address - Fax:601-445-1923
Practice Address - Street 1:394 IMPERIAL LN SW
Practice Address - Street 2:
Practice Address - City:BOGUE CHITTO
Practice Address - State:MS
Practice Address - Zip Code:39629-8231
Practice Address - Country:US
Practice Address - Phone:601-996-1758
Practice Address - Fax:601-797-8406
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS176192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000126454Medicaid
LA3663198Medicaid
MS009120058Medicaid
LA2522183Medicaid