Provider Demographics
NPI:1841290707
Name:OMOLE, FOLASHADE (MD)
Entity type:Individual
Prefix:
First Name:FOLASHADE
Middle Name:
Last Name:OMOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:720 WESTVIEW DR SW STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1458
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:404-756-5274
Practice Address - Street 1:1513 CLEVELAND AVE
Practice Address - Street 2:BLDG 500
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6947
Practice Address - Country:US
Practice Address - Phone:404-756-1205
Practice Address - Fax:404-756-1229
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000877599Medicaid
H33422Medicare UPIN
GA000877599Medicaid