Provider Demographics
NPI:1659578334
Name:OMOLAYO, OLUMUYIWA O (MD)
Entity Type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:O
Last Name:OMOLAYO
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 1:1364 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-6382
Mailing Address - Fax:404-778-5495
Practice Address - Street 1:1364 CLIFTON RD NE # TECA4330
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-6382
Practice Address - Fax:404-778-5495
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128588207R00000X
GA069906207R00000X
GA69906208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208905157Medicare PIN
ILIL3270634Medicare PIN