Provider Demographics
NPI:1255398459
Name:OMOTAYO, ADEKUNLE FESTUS (MD)
Entity type:Individual
Prefix:
First Name:ADEKUNLE
Middle Name:FESTUS
Last Name:OMOTAYO
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:PO BOX 15349
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-5349
Mailing Address - Country:US
Mailing Address - Phone:850-383-3445
Mailing Address - Fax:
Practice Address - Street 1:1491 GOVERNORS SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3049
Practice Address - Country:US
Practice Address - Phone:850-383-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 82543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E6542ZMedicare ID - Type Unspecified
H52002Medicare UPIN