Provider Demographics
NPI:1003436197
Name:OMO IJESA PLLC
Entity type:Organization
Organization Name:OMO IJESA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AKINBOLA
Authorized Official - Middle Name:ADEWOLE
Authorized Official - Last Name:AJAYI-OBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-345-8981
Mailing Address - Street 1:PO BOX 7362
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37111-7362
Mailing Address - Country:US
Mailing Address - Phone:510-345-8981
Mailing Address - Fax:
Practice Address - Street 1:7309 E 28TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5505
Practice Address - Country:US
Practice Address - Phone:510-345-8981
Practice Address - Fax:520-253-7229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-20
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZFA7154521OtherDEA