Provider Demographics
NPI:1831117522
Name:GOMIH, AYOOLA K (MD)
Entity Type:Individual
Prefix:
First Name:AYOOLA
Middle Name:K
Last Name:GOMIH
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 1:398 W 80TH PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5432
Mailing Address - Country:US
Mailing Address - Phone:219-791-0615
Mailing Address - Fax:219-791-0619
Practice Address - Street 1:398 W 80TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5432
Practice Address - Country:US
Practice Address - Phone:219-791-0615
Practice Address - Fax:219-791-0619
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032453B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100169870AMedicaid
627640AMedicare ID - Type Unspecified
IN100169870AMedicaid