Provider Demographics
NPI:1841233541
Name:OMOGBEHIN, ADEDAMOLA (MD)
Entity Type:Individual
Prefix:
First Name:ADEDAMOLA
Middle Name:
Last Name:OMOGBEHIN
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 1:110 IRVING STREET NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010
Mailing Address - Country:US
Mailing Address - Phone:202-877-3925
Mailing Address - Fax:804-355-6031
Practice Address - Street 1:110 IRVING STREET NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010
Practice Address - Country:US
Practice Address - Phone:202-877-3925
Practice Address - Fax:804-355-6031
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD32344174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037632900Medicaid