Provider Demographics
NPI:1932164456
Name:OTAIGBE, OMOLARA (MD)
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:
Last Name:OTAIGBE
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 1:6600 U S HIGHWAY 98
Mailing Address - Street 2:SUITE B
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8441
Mailing Address - Country:US
Mailing Address - Phone:601-261-2727
Mailing Address - Fax:601-261-9847
Practice Address - Street 1:6600 U S HIGHWAY 98
Practice Address - Street 2:SUITE B
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8441
Practice Address - Country:US
Practice Address - Phone:601-261-2727
Practice Address - Fax:601-261-9847
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126731Medicaid
MS512I080038Medicare PIN
MS00126731Medicaid