Provider Demographics
NPI:1568571305
Name:OMOTADE, ADERONKE OLUYEMISI (MD)
Entity Type:Individual
Prefix:DR
First Name:ADERONKE
Middle Name:OLUYEMISI
Last Name:OMOTADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 GRINDALL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4103
Mailing Address - Country:US
Mailing Address - Phone:540-798-2345
Mailing Address - Fax:
Practice Address - Street 1:2700 LIGHTHOUSE PT E STE 260
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4791
Practice Address - Country:US
Practice Address - Phone:410-801-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239732207R00000X
MDD00679262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD416025800Medicaid
MD416025800Medicaid