Provider Demographics
NPI:1851966865
Name:OMOTOSHO, OLUWATOSIN GRACE (MD)
Entity Type:Individual
Prefix:
First Name:OLUWATOSIN
Middle Name:GRACE
Last Name:OMOTOSHO
Suffix:
Gender:F
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:FAMILY MEDICINE RESIDENCY PROGRAM ST. JOSEPH MERCY
Mailing Address - Street 2:7575 GRAND RIVER AVENUE, SUITE 208
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114
Mailing Address - Country:US
Mailing Address - Phone:810-844-7940
Mailing Address - Fax:810-844-7960
Practice Address - Street 1:FAMILY MEDICINE RESIDENCY PROGRAM ST. JOSEPH MERCY
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114
Practice Address - Country:US
Practice Address - Phone:810-844-7940
Practice Address - Fax:810-844-7960
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2022-12-02
Deactivation Date:2022-11-14
Deactivation Code:
Reactivation Date:2022-12-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program