Provider Demographics
NPI:1811219355
Name:OMORUYI, ESEOSA CHRISTINE
Entity Type:Individual
Prefix:DR
First Name:ESEOSA
Middle Name:CHRISTINE
Last Name:OMORUYI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12164 CENTRAL AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1903
Mailing Address - Country:US
Mailing Address - Phone:734-353-9703
Mailing Address - Fax:
Practice Address - Street 1:12164 CENTRAL AVE STE 220
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-1903
Practice Address - Country:US
Practice Address - Phone:301-218-1862
Practice Address - Fax:301-218-1864
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist