Provider Demographics
NPI:1770196479
Name:OMITOOGUN, OLADIMEJI A (PT)
Entity Type:Individual
Prefix:
First Name:OLADIMEJI
Middle Name:A
Last Name:OMITOOGUN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 NORTHLINE AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7613
Mailing Address - Country:US
Mailing Address - Phone:336-545-5000
Mailing Address - Fax:336-544-1216
Practice Address - Street 1:3200 NORTHLINE AVE STE 160
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7613
Practice Address - Country:US
Practice Address - Phone:336-545-5000
Practice Address - Fax:336-544-1216
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP193302251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic