Provider Demographics
NPI:1982640538
Name:ADEWALE, OMOSALEWA O (MD)
Entity Type:Individual
Prefix:
First Name:OMOSALEWA
Middle Name:O
Last Name:ADEWALE
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 1:1150 N 35TH AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-5424
Mailing Address - Country:US
Mailing Address - Phone:954-265-7925
Mailing Address - Fax:954-276-0279
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5424
Practice Address - Country:US
Practice Address - Phone:954-265-7925
Practice Address - Fax:954-276-0279
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2997207RC0000X
FL124297207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P0282OtherBCBS OF TEXAS
TX179045301Medicaid
TX8G3028Medicare ID - Type Unspecified