Provider Demographics
NPI:1518384619
Name:OMOLE, OLUWATOSIN (MD, MPH)
Entity Type:Individual
Prefix:
First Name:OLUWATOSIN
Middle Name:
Last Name:OMOLE
Suffix:
Gender:M
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:P.O. BOX 87
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207
Mailing Address - Country:US
Mailing Address - Phone:210-358-9172
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-358-3441
Practice Address - Fax:210-358-5944
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR3169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine