Provider Demographics
NPI:1841461134
Name:OMOTOLA, AARON PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:AARON
Middle Name:PATRICK
Last Name:OMOTOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 130B
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6704
Mailing Address - Country:US
Mailing Address - Phone:618-463-7600
Mailing Address - Fax:618-463-7601
Practice Address - Street 1:4 MEMORIAL DR STE 130B
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-463-7600
Practice Address - Fax:618-463-7601
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.LSU.ORS207X00000X
MO2010011917207XX0005X
IL036125644207XX0005X
IL036-125644207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine