Provider Demographics
NPI:1225598907
Name:OMOTOSO, KEMI A (MD, MHSA)
Entity type:Individual
Prefix:MS
First Name:KEMI
Middle Name:A
Last Name:OMOTOSO
Suffix:
Gender:F
Credentials:MD, MHSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1118
Practice Address - Country:US
Practice Address - Phone:516-734-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3110172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology