Provider Demographics
NPI:1760560098
Name:PHILLIPS, OMOLARA LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:OMOLARA
Middle Name:LOUISE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:6810 N STATE ROAD 7
Mailing Address - Street 2:SUITE 268
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073
Mailing Address - Country:US
Mailing Address - Phone:954-617-8137
Mailing Address - Fax:757-788-0969
Practice Address - Street 1:16158 SOUTH MILITARY TRAIL
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6502
Practice Address - Country:US
Practice Address - Phone:561-495-0522
Practice Address - Fax:757-788-0969
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD00598782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659424448Medicaid
VA015261H14Medicare PIN
VA1659424448Medicaid